General-practice-based nurse specialists-taking a lead in improving the care of people with epilepsy.

Epilepsy is almost as common as diabetes and some 750 people with epilepsy die suddenly and prematurely each year. Unfortunately, the management of epilepsy has been much neglected and services often remain fragmented and difficult for patients to understand. We employed a nurse specialist in epilepsy to work with practice nurses in a group of general practices to promote better care, to make patients aware of sources of help and support, and to provide information about issues such as driving, employment and pregnancy. Over 70% of patients with epilepsy attended 'clinics' run by the specialist nurse and many previously unidentified problems were successfully resolved-including misdiagnosis, over-medication and lack of awareness of the side-effects of antiepileptic drugs. Nurse specialists in epilepsy, working with groups of general practices but in collaboration with hospital specialists and voluntary organizations, can take a lead role in facilitating joint working between all those involved in service provision, in training practice nurses and others in the special needs of people with epilepsy and in providing support in hospital clinics.

Life expectancy calculations for postcode sectors and their use for monitoring inequalities in the nation's health.

OBJECTIVE: To describe how life expectancy calculations can be used to demonstrate differences in mortality between populations of different socioeconomic status at each population census. DESIGN: Population data were obtained in five-year age-sex and deprivation groups at postcode sector level for the Greater Glasgow Health Board area for the censuses of 1981 and 1991. The numbers of deaths for the same groups were obtained for the three-year periods 1980-82 and 1990-92. Life expectancy tables were derived by applying mortality rates calculated from these data to a synthetic cohort of individuals. Regression analyses were applied to the tables thus derived to examine the relationships between census period, level of deprivation and life expectancy. RESULTS: Over the period 1980/82 to 1990/92 life expectancy of the age group 0-4 years increased by 2.1 years in males and 2.9 years in females, increases being greater in the more affluent areas. Differences in life expectancy between the geographically defined most deprived and most affluent areas increased from 7.4 to 9.0 years in males and from 5.9 to 6.0 years in females. CONCLUSION: Life expectancy is increasing in all socioeconomic groups, but particularly in the most affluent. We suggest that life expectancy values should be published routinely for different socioeconomic groupings. Over time these would illustrate more clearly the relationships between health policy and health outcomes, and would demonstrate whether policies are reducing inequalities and generally improving health.

The use of mapping in public health and planning health services.

The availability of relatively inexpensive, user-friendly geographical information systems, with a steadily extending range of analytic and other facilities, provides a powerful tool for the analysis and display of the increasing number of health-related data sets, and for their greater accessibility. Relationships between several sets of variables can become immediately apparent from a map in a way that is much more difficult to comprehend from a table or description. It is also easy to define ad hoc areas, such as the area adjacent to a possible toxic point source or to a main road, in terms of unit postcodes and Census output areas, to determine standardized rates for mortality and hospital admissions. Apart from the geographical information system itself, the basic requirements are access to relevant data sets including Census data, and to the central postcode directory, which provides grid references for unit postcodes and permits matching of postcoded health events to Census output areas.

The public health uses of the Scottish Community Health Index (CHI).

Each of the 15 Health Boards in Scotland maintains a computer file of its residents who are registered with a general practitioner; this is known as the Community Health Index or CHI. The CHI allows a variety of demographic data and indicators of health to be analysed on either a geographic or general practice base, or both simultaneously. The considerable potential of the CHI as a public health tool may be of interest to health authorities outside Scotland which are developing wider uses for their own family practitioner registers.

Is lead in tap water still a public health problem? An observational study in Glasgow.

OBJECTIVE: To assess the relation between tap water lead and maternal blood lead concentrations and assess the exposure of infants to lead in tap water in a water supply area subjected to maximal water treatment to reduce plumbosolvency. DESIGN: Postal questionnaire survey and collection of kettle water from a representative sample of mothers; blood and further water samples were collected in a random sample of households and households with raised water lead concentrations. SETTING: Loch Katrine water supply area, Glasgow. SUBJECTS: 1812 mothers with a live infant born between October 1991 and September 1992. Blood lead concentrations were measured in 342 mothers. MAIN OUTCOME MEASURES: Mean geometric blood lead concentrations and the prevalence of raised tap water lead concentration. RESULTS: 17% of households had water lead concentration of 10 micrograms/l (48.3 nmol/l) or more in 1993 compared with 49% of households in 1981. Tap water lead remained the main correlate or raised maternal blood lead concentrations and accounted for 62% and 76% of cases of maternal blood lead concentrations above 5 and 10 micrograms/dl (0.24 and 0.48 mumol/l) respectively. The geometric mean maternal blood lead concentration was 3.65 micrograms/dl (0.18 mumol/l) in a random sample of mothers and 3.16 micrograms/dl (0.15 mumol/l) in mothers whose tap water lead concentrations were consistently below 2 micrograms/l (9.7 nmol/l). No mother in the study had a blood lead concentration above 25 micrograms/dl (1.21 mumol/l). An estimated 13% of infants were exposed via bottle feeds to tap water lead concentrations exceeding the World Health Organisation's guideline of 10 micrograms/l (48.3 nmol/l). CONCLUSIONS: Tap water lead and maternal blood led concentrations in the Loch Katrine water supply area have fallen substantially since the early 1980s. Maternal blood lead concentrations are well within limits currently considered safe for human health. Tap water lead is still a public health problem in relation to the lead exposure of bottle fed infants.

The Measles/Rubella Immunisation Campaign in Greater Glasgow: a success in collaboration.

The recent UK campaign to immunise schoolchildren against measles and rubella involved, in Greater Glasgow, about 143,000 schoolchildren attending 300 primary, 63 secondary and 54 special schools administered by Strathclyde Regional Council and 21 private schools. The campaign involved a large number of individuals and professional groups, both in education and the health service. Despite-or perhaps because of-the magnitude and complexity of the task, and the very short time available, the campaign was planned and brought to a successful conclusion with a quite remarkable degree of enthusiasm and goodwill. As a result it was possible to immunise 88% of eligible schoolchildren in an area which has 46% of its population living in the most deprived postcode sectors (Carstairs categories 6 and 7) and to record all results on computer file as a permanent and readily accessible record. The campaign provided an unusual opportunity to demonstrate how effectively different organisations within the health service can collaborate with one another and with other agencies when there is a clear goal and deadline imposed.

Declining prevalence of hydrocephalus.

Data from the Glasgow Register of Congenital Anomalies were used to compare the recent prevalence of primary hydrocephalus with that of anencephalus and spina bifida. Between 1974 and 1985, the prevalence rates of all three conditions declined significantly and virtually in parallel, a phenomenon suggestive of a common aetiology.

Recent trends in the prevalence and secondary prevention of Down's syndrome.

Examination of data from the Glasgow Registry of Congenital Anomalies indicated that 184 infants with Down's syndrome were born (live or still) to mothers residing in the Greater Glasgow Health Board area between 1974 and 1986 inclusive. This represents a period prevalence of 1.1 per 1000 total births. Despite a strongly positive correlation between prevalence and maternal age, most of the Down's syndrome infants were born to mothers aged under 35 years. There was no evidence either of a recent decline in the annual prevalence rate or of a changing pattern of risk in relation to maternal age. Antenatal diagnosis resulted in the termination of less than a tenth of all Down's syndrome pregnancies. These findings point to a need for further aetiological research, for continued epidemiological monitoring, for an improvement in the relatively low uptake of amniocentesis by older mothers, and for the development of a screening test which can be offered to the entire pregnant population.

Screening for congenital neural tube defects in a high-risk area: an epidemiological perspective.

Data from the Glasgow Register of Congenital Malformations were used to investigate the extent of the recent decline in the prevalence of anencephaly and spina bifida, and the contribution of antenatal screening to it. Over the period 1974-85 inclusive, 303 pregnancies with an anencephalic foetus were diagnosed, representing an "adjusted" prevalence of 1.9 per 1000 total births, of which 179 (59%) were terminated following antenatal screening. There were 364 pregnancies with a spina bifida foetus representing an "adjusted" prevalence of 2.3 per 1000 total births, of which 84 (23%) were terminated. Over the study period, the "adjusted" prevalence of anencephaly fell by 50% while the birth prevalence fell by 89%; the "adjusted" prevalence of spina bifida fell by 38% while the birth prevalence fell by 76%. It was concluded that although the birth prevalence of both defects (particularly anencephaly) would have declined substantially in the absence of screening, the West of Scotland programme should continue.

Tailoring health services to the needs of individual communities.

In order to assess the need for community health services in different neighbourhoods within Greater Glasgow, it was decided to present a wide variety of health information for each community as a set of summary profiles. These profiles clearly demonstrate that the same areas have the highest standardised mortality ratios, the least favourable socioeconomic circumstances, the highest hospital admission rates, and the poorest child health characteristics. The greatest benefit in overall health would be achieved by targeting community resources on these disadvantaged communities. Adoption of this policy should reduce existing inequalities in health, and we argue that such 'positive discrimination' is implied in the formulae used in Great Britain for allocation of revenue expenditure for community services. The health profiles that we describe provide the baseline information necessary to target community services to particular communities according to objective measures, and to evaluate the effectiveness of new and existing methods of health promotion.

Epidemiology of facial clefts.

Data from the Glasgow Register of Congenital Malformations were used to investigate the epidemiology of congenital facial clefts over the period 1974-85. Facial clefts were registered in 247 infants representing a prevalence of 1.56 per 1000 total births. Cleft palate was more common than cleft lip, with cleft lip and palate occupying an intermediate position. More than half of the infants with facial clefts had associated defects. Males predominated for cleft lip; females for cleft palate. Cleft lip (alone) was more common in babies born to women aged 35 years and over. Sudden declines in registered prevalence were observed in 1978 and 1985. Clefts were more common in socioeconomically deprived areas of the city. In comparison with data from elsewhere, Glasgow seems to have a low rate of cleft lip, a high rate of cleft palate, and a high rate of associated defects. Many of the findings of cleft palate in Glasgow could be explained by the interaction of an unidentified environmental teratogen with a susceptible population.

Analysis of death rates in the population aged 60 years and over of Greater Glasgow by postcode sector of residence.

Using computer tapes of death registrations for the period 1980-2, and paper copy of population data for the 1981 census, death rates were calculated for the population resident in each of the 112 postcode sectors that make up the area served by the Greater Glasgow Health Board. Rates were calculated for both sexes in combination for each of the age groups 60-64, 65-69, 70-74, 75-79, 80-84, and 85 years and over. The difference in the mean death rate for the 22 postcodes in the quintile with the highest rates and the 22 postcodes in the quintile with the lowest rates was just over twofold in the 60-64 age group, just under twofold in the 65-84 age groups, but only 1.2-fold in the age group 85 years and over. There was marked consistency between the various age groups in the mortality rating for the postcode sectors, the postcode sectors with the highest death rates being located entirely in the more disadvantaged areas of the city and suburbs. The geographical mortality pattern for the older population was very similar to that (standardised for age and sex) in the 15-59 year age group.