Issue 7: Nov 2013

A BIG SCOTTISH QUESTION - "HOW DO WE BECOME A HEALTHIER PEOPLE?"

By Stephen Oswald

There is a tsunami of debate, fact and propaganda about to hit the Scottish people around sovereignty. Exposed to the information, Scotland’s citizens (aged 16 or above) are expected to be sufficiently informed to make and then live with a very big decision on 18/09/14.

The drive for increased self-determination in our health does not attract the same energy, debate, political or media subscription. But what could be more important?

The NHS Scotland 2012 – 2017 strategy document “A Fairer Healthier Scotland” confirms that health inequalities in Scotland are the widest in Western and Central Europe.

In Scotland we have the government backed HUB initiative (LIFT in England) which is designed to increase joint working across the public sectors, harness private sector expertise and community participation. As a relatively new concept it already has had some success in breaking down the institutional barriers and funding silos that currently exist in the public sector and invest in community led initiatives. This approach can reduce waste, directly save on expenditure, and ultimately deliver public health and social care services more democratically. Extending this approach in Scotland needs to be debated.
 
The UK as a whole still measures up poorly compared with other countries in terms of health - it ranked 12 out of the 19 countries in a recent Lancet study.* Average life expectancy (LE) in the UK is now 79.9 years with average healthy life expectancy (HLE) of 68.6 years.
 
However, Scotland, if viewed independently, in this study would be in an undisputed last place.  The most recent annual estimates from ScotPHO are for Scottish boys born in 2011 to live 76.6 years on average, 60.4 of these in a 'healthy' state. Girls born in 2011 would be expected to live 80.9 years on average, 62.7 of these years being 'healthy'.**

We need to take the long view and engage with people to get more involved in shaping and constantly evolving the services they need.

There are considerable variations in LE and HLE at birth in Scotland among different geographical and socio-economic groupings. So it is not the weather! For example, in 2009-10, male LE at birth ranged from 81.0 years in the least deprived quintile to 70.1 years in the most deprived quintile. For male HLE at birth, the figures were 68.5 and 50.0 years respectively. A potentially uncomfortable 18.5 years for the individuals and expensive for the State.

The Lancet study lists the main health risk factors in the UK as:

•    Tobacco smoke (including second-hand smoke)
•    High blood pressure
•    Obesity
•    Too little exercise
•    Alcohol use
•    Poor diet
 
The NHS Scotland 2012 – 2017 strategy document “A Fairer Healthier Scotland” confirms that health inequalities in Scotland are the widest in Western and Central Europe. The same document explains that “the widest inequalities are currently amongst young adults who are affected most by drug and alcohol related illness, suicide and violence”. Studies at Glasgow University found that the most important determinants of these inequalities are around low educational attainment and to be resident in a deprived area. According to NHS Greater Glasgow and Clyde in the ward area of Carlton, Glasgow the average LE for a male is a shocking 54 years! 

Addressing this unacceptable situation needs us to change from a system of mostly treating illness to one with much greater emphasis on prevention. This has been stated many times before and there are some very good initiatives that support that this approach is effective. The ban on smoking in public places, together with a ban on tobacco advertising and sponsorship in sport are good examples of how governments can take radical action. In Scotland 23% (20% in England) of adults smoked in 2012 which continues a general downwards trend in the proportion of adults who smoke.*** In 1999 it was over 30%. However, smoking is still the greatest single cause of illness and premature deaths in Scotland (and the rest of the world) so there is certainly plenty of scope to further eliminate the harm caused by tobacco.

...becoming a healthier nation won’t be achieved by the traditional health sector alone; it needs a long term strategic priority approach from government, a multi agency effort, increased community involvement (and genuine “buy in”) and fundamental change in our lifestyle.

To help address the main health risks we need all our people to have good basic communication skills, self-confidence, knowledge and the belief they have a positive future. We need to educate our children at home and at school about their bodies, diet (withdrawing the sweet “pink” milk still offered in many Scottish schools would be a good start) exercise and the harmful effects of alcohol and drug abuse.

In 2009 the volumes of alcohol (beer, spirits and wine) sold in Scotland were 2.4 times more than England and Wales per person. We need to reduce alcohol consumption though legislation and education.

We need to be more creative with our housing provision by “place making”, reducing car dependency, creating amenity, a sense of security and connect all this with good public facilities rather than simply building more housing units. We need to make leisure facilities more accessible and generally have more support to enable us to make better, healthier lifestyle choices. Then, we will be better equipped and more responsible for our health decisions.
 
We need to take the long view and engage with people to get more involved in shaping and constantly evolving the services they need. To connect primary health services with housing services, employment/ training services, social care services, art, enterprise and link with educational institutions, local groups, businesses and charities. The best known and most successful example of this type of project is the Bromley by Bow Centre in East London. (above) http://www.bbbc.org.uk/  

Although this type of project is rare and difficult to achieve it should be considered an evolutionary, not revolutionary idea! Many of the community activities described above already happen but lack a focal point and certainly integration with each other.

A community initiative such as outlined above could form a “community hub” and offer a more holistic, cost effective approach to improving health outcomes and, if shaped by the community, should be more sustainable. Linked to housing development a community hub could create employment, social benefits in terms of increasing the sense of neighbourhood, focus common effort and reinforce the notion of self-care. Economic benefits can also be delivered in terms of reducing the pressure on our clinical and GP services by diverting non-medical presentations  to more suitable professionals and organisations who can attempt to deal with the root of the problem (housing, training, mental health, employment, education, social services etc).

In terms of Estate requirements the community hub could be located in foyer spaces of new or existing public buildings or GP centres with access to bookable meeting rooms. Staffing and running the hub will be by local voluntary and charitable groups with links to GP, health and social care professionals. 

So becoming a healthier nation won’t be achieved by the traditional health sector alone; it needs a long term strategic priority approach from government, a multi-agency effort, increased community involvement (and genuine “buy in”) and fundamental change in our lifestyle. Most importantly it needs communities and individuals to be endowed with a knowledge and services that equips them to take more responsibility for their own health and well-being.

 
Stephen Oswald was a director of two LIFT companies based in London between 2005-2012 and relocated to East Lothian in 2013. He is currently a non-executive board director of Castle Rock Edinvar.

* UK health performance: findings of the Lancet’s Global Burden of Disease Study 2010.

** The Scottish Public Health Observatory (ScotPHO) collaboration is co-led by ISD Scotland and NHS Health Scotland, and includes the Glasgow Centre for Population Health, National Records of Scotland and Health Protection Scotland.

*** The Scottish Household Survey

**** NHS National Services Alcohol Statistics Scotland

By Stephen Oswald

Issue 7: Nov 2013

Issue 7: Nov 2013

HEALTH, WELL BEING AND AGEING: SCOTLAND 2020

Re-energising the move towards integrated care

Scotland's move to integrated care can learn from elsewhere by focussing on two key differentiators between successful partnerships and those paying lip service to integrated working: Shared outcomes and common language is one, the other is demonstrating mutual investments and mutual benefits.

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