Associate Feature: Urgent action required: How prevention can transform Scotland’s health

“Around half of ill-health is preventable. 

“Imagine the difference that preventing even a proportion of that would make on the delays that people are experiencing in the NHS just now.”

It’s not often a health leader offers up a powerful, persuasive answer to cutting the eye-watering burden on the NHS and making other public services more sustainable, but Paul Johnston, the chief executive of Public Health Scotland (PHS), is clear and determined in his diagnosis and prescription. 

After a year in post – a year spent talking to hundreds of people in PHS and beyond – he is convinced that prevention is the key to reforming the NHS, making key local services more secure and reducing the chasm of difference in how long people live in deprived compared to wealthy communities. There are endless headlines about the challenges facing the health service, but improving Scotland’s long-standing health challenges goes much further than looking at the NHS, with collaborative action required across the public sector.

“I would say prevention is the thing that will enable the health service truly to recover from the pressures that it’s experiencing,” he says. “So much of the pressure that our public services are under presently is down to avoidable harm.” 

As the NHS budget grows to cope with rising demand, the squeeze on other departments increases. So preventing harm won’t just help the NHS, Johnston points out, it will free up money for other critical areas of public spending.

The sense of urgency he feels is obvious. As he puts it, “this is not a nice thing to do, it’s absolutely essential”. 

“The reality is that Scotland’s health is worsening at present,” he explains. “We saw good progress in terms of increasing life expectancy and reducing health inequalities year-on-year from the start of this century until about 2013. About 10 years ago progress stalled and in the last few years we’ve seen things getting worse. 

“In particular we’ve seen growing inequality in health. We’ve seen life expectancy reduce most starkly for the poorest.

“Set against that we know all the pressures the NHS is under – the recent Audit Scotland report on the NHS makes that abundantly clear. 

“But on top of that, the burden of disease is forecast to increase 21 per cent over the next 20 years if current trends continue.

“We cannot accept that those trends continue.  We must interrupt those trends.” 
It’s four years since PHS was set up. Its vision, set by a ministerially appointed board, is to help build a Scotland where “everyone thrives”. 

When it launched, on 1 April 2020, the pandemic had just begun. Lockdown had been imposed only eight days earlier. Staff immediately found themselves working on Covid surveillance and testing, which led to them playing a crucial role in Scotland’s pandemic response. PHS continues to be closely involved in pandemic preparedness. 

But the team are now focusing again on Scotland’s underlying health challenges. Johnston has been trying to apply preventive principles in his own life. A regular Park Runner, he is soon to do the West Highland Way with his two sons.

But he stresses that preventing ill-health at population level is about more than people’s personal choices. It requires action on multiple fronts.

The outlook at present is bleak. People in Scotland die younger than in any other western European country, with poor communities bearing the brunt of ill-health. Men in the 20 per cent most deprived communities can expect to live in good health only until their mid 40s, while those living in the wealthiest areas will stay healthy until their 70s.

Improving that picture requires action across all departments of government, local government and in wider society. 

Johnston explains why with reference to the “building blocks of health”. 

Evidence from the King’s Fund indicates that health behaviours, like whether and how much someone smokes, drinks or takes drugs, are indeed significant and account for 30 per cent of what makes for health. 

The NHS represents a further 20 per cent of what makes for health through things like vaccination, screening, diagnostics and acute healthcare. 

“But let’s not miss the fact that about 40 per cent of what makes for health is the social and economic context in which we live,” Johnston observes. “Another 10 per cent is the physical environment you live in. 

“This is about whether we have enough money, a decent education, decent housing and a good job. That’s what makes for health. 

“PHS is absolutely interested in homelessness, quality of housing, provision of childcare.
“It really is about a whole range of factors that make for health. We need quite deliberately to take action across all those factors.”

Professor Sir Michael Marmot of University College London, a world authority on health inequalities, has produced the evidence-based “Marmot principles”, identifying eight areas that require action to drive down health inequality. They include early years support, a decent education, a good job, a decent living standard, a healthy place to live, and tackling racism and discrimination. “What we need is action on all of them,” says Johnston.

He highlights examples of where preventative action has already been taken in Scotland, such as vaccinations and the introduction of the Scottish Child Payment, worth £25 a week for each child in families receiving certain benefits. Some vaccinations can have an immediate effect in preventing ill-health but the Scottish Child Payment is an example of a measure that will take time to feed through in higher life expectancy and reduced pressure on public services. 

Other examples include the HPV vaccine to prevent cervical cancer and the Childsmile dental initiative. 

Improving early years support and childcare, an ongoing policy, will also ultimately improve health, particularly for those living in deprived communities.

Politicians, however, are always under pressure to deliver quick results. They’re also working within painfully tight budgets. Finding the cash to devote to it is challenging at a time when every penny is being spent on keeping the health service running.

“The last thing I’m suggesting is that it’s easy,” says Johnston. 

“But firstly, some prevention doesn’t cost very much at all. So smoking – the measures taken by the Scottish Parliament to address harms from smoking, starting with its flagship smoking in public places legislation: that has cut pressure on the NHS and reduced illness and death from smoking. Crucially it has helped people live longer, healthier lives. How much did that cost? Of course there were implementation costs but in the scheme of things it was not an expensive intervention.

“How can we learn from that and apply that determinedly in other areas?

“Action is needed in areas such as the marketing and advertising of alcohol. We know from other countries that could help significantly in reducing numbers of deaths.

“In relation to food, action is needed on a population basis. It’s not going to be expensive but it is going to have positive consequences.”

Marmot calculates that prevention measures can be three to four times more cost effective than investing in treatment.

Even so, prevention can only be prioritised with political backing, which is why Johnston stresses the importance of cross-party support for this vision of a healthier Scotland. He has recently written to every opposition party at Holyrood requesting meetings with health spokespeople to discuss the range of measures PHS evidence highlights as necessary to cut alcohol harm in a lasting way.

Another area for urgent action is unhealthy food. He would like to see “a united focus” on these measures in parliament.

“In reality we will not see them become law without some cross-party support,” says Johnston. “PHS has joint accountability to the Scottish Government and Cosla, and I see broad agreement on most of the issues that make for heath.

“Where I see delay is when we don’t secure the cross-party support that we need. 

“We’ve got a real opportunity in Scotland to be bold.”

It’s hard to see an alternative. He says: “It is vital that we do not allow a 21 per cent increase in disease in Scotland because I can’t see how we could give people the support they would expect if we let that come about. 

“Fundamentally it’s inconsistent with our vision for a Scotland where people are flourishing and living healthier, longer lives.” 

This article is sponsored by Public Health Scotland

https://publichealthscotland.scot/