In Sickness and in Health: What now for public health in Scotland?

Covid prevalence is still high and there are 'serious challenges' ahead

It was March 2020 when Scotland first locked down to counter coronavirus. Two years later, life is now at the closest to normal since the pandemic hit and all legal restrictions aside from the wearing of face coverings have been eased.

Case numbers remain high – so high, in fact, that the number of people hospitalised due to Covid has reached a new record – but most of those who test positive have been vaccinated and avoid the worst of the symptoms we now know and fear; high fever, debilitating brain fog, severe breathing problems.

The pandemic is not over – not by a long chalk – but we are told it is easing, finally.

And so as efforts continue to measure infection patterns, monitor the threat of new strains and mitigate the worst harms on the economy, public health experts are asking what comes next.

Professor Linda Bauld of Edinburgh University says there are “serious challenges” ahead, including the cost of living crisis, chronic conditions and mental health.

As an expert in behavioural science and public health, and as interim chief social policy advisor to the Scottish Government, Bauld has become one of the most familiar commentators on Covid, making frequent media appearances to discuss vaccinations, masks and more. The work has been so intense that she took just four days off work across the 12 months from February 2020, but TV and radio slots have now lessened and that’s giving her more time to assess.

Before Covid, Bauld spent years seeking solutions to some of the country’s most entrenched health problems - cancer, drug abuse, alcoholism, tobacco, obesity. All of these, she says, need renewed focus as part of our country’s collective recovery.

But there’s no magic cure for any of it. Far from emptying, several hospitals are still working at, or close to, capacity – something Bauld doesn’t see alleviating “any time soon” as the virus, and a huge backlog of patients requiring other treatments, continue to keep beds occupied. “It’s difficult to focus on recovery when we are still dealing with the response,” she says, “because Covid is still causing disruption and taking time and effort”.

And those chronic issues that led to Scotland gaining the title of ‘sick man of Europe’ haven’t gone away. A clutch of reports have shown how these entrenched issues continued to affect lives amidst the biggest health crisis in living memory. Alcohol-related deaths rose to 1,190 in 2020, with men, the over-45s and people from the most deprived communities the worst affected, according to the latest figures from Public Health Scotland (PHS). Meanwhile, the most recent drug deaths figures show 1,300 lost their lives to substance misuse in 2021.

Non-Covid deaths from cancer, circulatory conditions, dementia and other causes were lower than normal until midway through last year but were higher than anticipated from July onwards. It’s a complicated picture, experts say, with some patients choosing not to seek help for their ailments out of fear of placing added strain on an already over-burdened NHS, and others affected by limitations on services and appointments caused by the diverting of efforts to the fight against Covid.

There is “no debate whatsoever” that cancer cases are now being caught at a later stage than before the pandemic, according to Macmillan Cancer Support policy manager Peter Hastie. “The cancer system was not good before the pandemic,” he told MSPs on the Covid-19 Recovery Committee recently, “and all of the problems that we knew existed have been exacerbated.”

While the public heard they were ‘all in this together’, evidence has proven that a person’s experience of the pandemic was strongly influenced by their circumstances. Predictably, those with the least resources suffered the greatest impacts from the economic contraction and lack of access to services.

Bauld believes tackling economic inequalities will be key to post-pandemic public health. Beating the lifestyle-linked chronic conditions that have plagued Scotland for generations is about policy, not just medicine, she says. “There are inequalities in Scotland which are decades, even a century, old but have become more acute because of the pandemic,” she explains. “We have not been talking about the causes of non-communicable disease because we have been dealing with a communicable disease. But 87 per cent of deaths in the UK are by non-communicable diseases. 

“The big burden is still cancer, heart disease, diabetes, respiratory conditions. The challenge is to reduce inequalities which is not about services, it’s about income and employment, and to prevent the 40 per cent of cancers caused by risk factors like alcohol and tobacco. We do need to shift our attention back to these.”

The cost of living crisis, Bauld says, is an emerging threat to the health of the nation. It’s the result of “the challenges introduced through Brexit, fuel poverty and the geopolitical developments with Ukraine”, she says, and “if people are spending a lot more on fuel and food, there are going to be more people in poverty, not less”. “To really make progress we have to improve people’s circumstances,” Bauld goes on.

According to analysis from Citizens Advice Scotland, more than 600,000 adults in Scotland either fell into debt during the pandemic or dropped deeper into the red. That’s despite the furlough payments available to workers whose jobs were kept open with state support through shutdowns and the scaling-back of many of the operations still able to trade.

Before we even got to lockdown, relative child poverty in Scotland was 24 per cent. All predictions are that this level is going to increase. Save the Children and foodbank network The Trussell Trust have issued a joint warning about the risks to younger people and the Scottish Government’s second Tackling Child Poverty Delivery Plan is aimed at will offering some hope to families who are now facing rocketing bills for food and power.

Professor Nicholas Sculthorpe of the University of the West of Scotland (UWS) is also convinced of the need to act on inequality to improve health. And he sees “significant overlap” between issues he says must emerge as national priorities – addressing common chronic conditions and finding solutions for those with long Covid, which is thought to affect around 100,000 people. That’s something he’s working on.

Sculthorpe and colleagues have compiled a list of more than 100 persistent symptoms of this very new health problem, which is difficult to diagnose and appears to affect more women than men. Nausea, skin complaints, diarrhoea, fatigue, sensory impairment and pulmonary symptoms are all on there. Those affected are often faced with cycles of “severe and debilitating symptoms”, remission, and “extreme symptom exacerbation,” they wrote in a November research paper. As an added complication, long Covid symptoms are disparate from acute Covid-19 symptoms and their severity is unrelated to that of the initial acute infection.

Patients and medics need clear diagnostic criteria for long Covid, Sculthorpe says, and, without this, diagnosis is “a bit of a lottery”. There is “an awful lot of overlap” between this and other areas of concern, he says. “People who had the very worst symptoms of Covid were often also those who had underlying health conditions, particularly vascular conditions.”

He and his colleagues are currently three-to-four months away from producing a report on the findings of their trial into the use of fitness trackers to manage some of these symptoms. Linked to a UWS app, the devices monitor activity levels and send warnings to wearers to slow down and rest when appropriate. Around 70 people are involved, but the team had to turn away some of those who wanted to join in. “Nurses wanted to take part but they have to have bare arms,” he explains. “They couldn’t wear the Fitbits.”

The devices are gathering useful data on the wearers, and Sculthorpe says that such data, shared across agencies, can help treat Scotland’s collective health needs. “It was a very big cloud,” he says of the pandemic, “but one of the silver linings was learning to work better between those who held different bits of data. I would hope that this will feed through into how we manage things, going forward.”

Bauld agrees that “we should seize and expand” the adapations made in services, including the use of digital technologies. It’s steps like this that can ease pressures in the system and offer improvements for patients, she says, while the release of the Test and Protect workforce will allow staff to return to other areas of the NHS, easing staff shortages. 

Public health services are “really just getting back on their feet”, she says, and across areas of care “people are exhausted”. “We have all aged,” Bauld says, calling for a new emphasis on mental health for those we rely on to keep us well. “People have said that to me, I have said it to other people. When you’re in a crisis everybody runs round and tries to go the extra mile. Some have been doing that repeatedly for two years now. It’s not a sustainable model.”

Professor Nicola Roberts of Glasgow Caledonian University has been monitoring the way nurses have coped throughout the pandemic and found high levels of stress, fatigue and anxiety, and a significant proportion of staff who were thinking of leaving their jobs. Addressing this, she argues, is key to staff retention – something we all need, if the country is to recover. “Things have to change,” she says.

“Younger and less experienced staff had higher anxiety and depression. We have to change things for everyone, not even just nurses but everyone who has been adversely affected by the pandemic, or we are not going to be able to keep them in the workforce. We need to be much more supportive as employers.

“A lot of people are now experiencing PTSD and burnout. We need much more mental health support.”

Mental health waiting times figures for the end of last year show almost 2,000 children and more than 4,500 adults had been waiting for more than a year for treatment. Bauld says it is time to do “what we have been saying for decades and never actually done” and really step up on mental health for all ages. “Children have been hugely affected,” Bauld says. “For younger children, there are signs of developmental delays, and for every age group there have been harms.”

We should, Bauld says, remember the bigger context – this has been a global pandemic and Scotland is not the only country wrestling with these issues. The World Health Organization (WHO) says countries in its European region “face daunting challenges in tackling health inequities” and reaching health-related sustainable development goals by 2030. Unless we “prioritise the health sector as never before,” according to WHO regional director for Europe, Dr Hans Henri P Kluge, we will “lose the chance we have” to make gains on obesity, alcohol consumption, tobacco usage and more.

That also means continued Covid vigilance, Bauld argues. “We are not going to be out of the global pandemic for another couple of years. There will be continued disruption in Scotland for the foreseeable future – but we are managing it well.”