Incremental gains are key to improving public health

Sir Harry Burns tells a story about how British cycling went from a history of mediocrity to becoming one of the most successful teams in the world.

The key, as he sees it, lay in the notion of complex adapted systems. Or, as the cycling team phrases it, in the aggregation of marginal gains.

Burns, himself a keen cyclist, saw the evidence for the improvement firsthand when Nicole Cooke went flying past him during a ride while on holiday in Majorca. A few months after overtaking him, he says, she won gold at the Beijing Olympics.

“There was one night I was cycling up this hill, which is around five or six kilometres long and it averages around seven per cent gradient, and then at the first hairpin there was the British cycling team van, with the trainer looking out the window. He was smiling at me as I was going past, and I realised someone was coming up behind me from the team. She went past me like I was standing still. She was just sitting on the saddle. My time up the hill was about 18 minutes, and afterwards they told me she’d done it in six.”

The British cycling team had struggled for years. In fact, there have even been claims – all unconfirmed – that some bike manufacturers actually refused to sell them equipment, through fear of looking ineffective by association.

The improvement in the team’s fortunes is often attributed to the arrival of Dave Brailsford as performance director, who brought a simple principle with his appointment. Incremental gains or complex adapted systems – call it what you like – but the key, as he saw it, was to make improvements, however small, in multiple areas, to help bring about massive gains in performance overall. Improving the health of a population or boosting cycling performance, the plan is the same.

Burns told Holyrood: “We need to be clever in the way we do things, through marginal gains across the whole of society. The problem with public health in the past is that people have tended to try and reduce problems to a single, linear explanation. That if we fix poverty, that health inequalities will go away, but it’s more complicated than that. Some years ago, I began to explore a different view when I came across this notion of complex adapted systems.

“British cycling took off when they began to see their problems of performance as being one that involved dozens and dozens of factors. If you tried 20 things and ten of them worked, and they all worked to give you a two per cent improvement in performance, and you did them consistently, then you got a 20 per cent improvement in performance. Previously, because of the academic approach being taken, they would try something and find there was only a two per cent improvement in performance and conclude it wasn’t the answer and drop it.

“My thinking was that the wellbeing of a population is absolutely an example of a complex adapted system. There are lots and lots of factors at play. So we began to think about ways of changing complex systems, and in thinking that through, it became clear to me that there’s a lot wrong with the way we conceptualise public wellbeing.”

For years, Burns explained, understanding of public health was based in Maslow’s hierarchy of needs – a pyramid which places things like food and water at the bottom, followed by security, then social cohesion, then relationships, with ‘self-actualisation’ at the top.

Burns said: “Maslow argued that the way people reached their very peak of capacity depended on their needs being met. You had to be able to eat and drink before you could hope to be at your peak. We began to realise that was wrong over the last couple of years. You start off in the family, with children learning they can be in control of their world and you get to the point they feel safe, they feel in control, they do well at school, they get jobs, they don’t go to jail, they tend to take exercise and not smoke.

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“Conventional public health is all about telling people what’s bad for them and encouraging them to do things like take exercise and eat healthily and so on. But the alternative model for public health is to create a society where people feel safe and in control of their lives, and then they will do all these other things. So, in essence, my thinking over the last few years has been to encourage the creation of wellbeing in early life. If you do that, you don’t have to worry so much about building more prisons, you don’t have to worry so much about drug use and so on. People will feel a sense of purpose and they will want to live a decent life.”

This change in approach goes well beyond health agencies, as recent years have seen the shift in thinking also increasingly evident in political rhetoric. SNP Westminster leader Ian Blackford’s pre-budget intervention was a case in point, with the Ross, Skye and Lochaber MP framing recent economic decisions in public health terms.

Coronavirus, clearly, has dominated the news agenda, but Blackford’s point went well beyond the spread of Covid-19. Warning that austerity was “impacting” public health, Blackford said: “This, I would say, has been about political choices over the last ten years… the monetary policy initiatives they have been enormous in their entirety over the course of the last ten years and ordinary people have paid a price.

“These are before you consider the impact of what coronavirus might do in the short term, and we hope that that is limited for all our interests, but there are signs which are there that austerity is impacting public health, is impacting life expectancy, is impacting infant mortality and government has got a responsibility to end austerity.

“There still is a squeeze on public finances that has been imposed by this government, now is the time to bring that to an end.”

The concept has clearly undergone enormous change over the last few decades. In fact, according to the Scottish Government, we are now in the ‘fifth wave’ of public health. The first, from 1830-1900, saw the beginnings of a structural approach, implemented through things like water sanitation, improved working conditions and cleaner cities. The second wave, from 1900 to 1950, then saw the next steps, through the first vaccinations and the introduction of antibiotics. The third, from 1940 to 1980, was based in a greater understanding of lifestyle-related diseases, while the fourth, from 1960 to 2000, was characterised by a focus on the social determinants of health outcomes, including a greater understanding of the role inequality plays.

The fifth wave, which health agencies identify as beginning in 2010, has seen a growth of partnership working. Driven by the Christie report, recent reforms have brought a review of the whole system, alongside the publication of six key priorities for public health.

Delivered in partnership between local and national government, the priorities are to create vibrant, healthy and safe places and communities, for children to “flourish” in early years, for good mental health, for a reduction in harm from alcohol, tobacco and other drugs, for a sustainable, inclusive economy with equality of outcomes for all, and where people eat well, have a healthy weight and are physically active.

So how can Scotland turn these objectives into reality? And how can the incremental gains in family life, which Burns identifies, be realised? That’s where Public Health Scotland (PHS) comes in.

Ten years on from the Christie report arguing for the need to shift to prevention in how we deliver Scotland’s public services, PHS will be responsible for reversing the downward trend in life expectancy, tackle persistent health inequalities and reduce unsustainable demands on public services.

Established by the Scottish Government and COSLA as a partnership between national and local government and chaired by Professor Jim McGoldrick, it will apply new and innovative uses of data, research and technology to develop solutions for Scotland’s public health challenges now and in the future.

As Jeane Freeman put it, writing for Holyrood: “The new body will bring together existing national public health assets in health improvement, health protection and healthcare, underpinned by significant data and intelligence expertise to take advantage of Scotland’s inherent data capabilities.

“It is in the innovative use of data and intelligence where we will be able to support our public services make better decisions and target resources more efficiently, and on the areas where the biggest gains in health can be achieved.

“Data will provide citizens with the information and power to make decisions about their own health and care and self-manage existing conditions more effectively. Data presents us with the opportunity to achieve a step change in the population’s health and deliver our future vision. Public Health Scotland will be at the forefront of this innovation.

“The new body will be established consistent with the principles set out in the Christie Commission on the Future Delivery of Public Services and draw on fully integrated corporate functions delivered on a shared services model – this will enable the organisation to realise efficiencies and economies of scale to deliver enhanced service capabilities and support wider transformation. 

“A decade on from Christie, Public Health Scotland will live and breathe these principles in how it functions and supports the wider system.”

And while it will take time to see what change PHS can bring about in helping Scotland meet the six objectives identified by the Scottish Government and COSLA, Burns sees the new organisation as offering an opportunity to take a new approach.

He said: “We need to think outside the box on this kind of thing. But I think there is some evidence that it is working. Every year the NSPCC report on the number of violent offences against children that have been reported in the four UK countries. In the time since they started recording, violent offences have doubled in England and tripled in Wales. In Scotland, they have decreased by 56 per cent over five years. That’s because increasingly we are talking about the importance of families, and government policy over the past few years has been to support things like the Family Nurse Partnership, the Early Years Collaborative, that kind of thing.

“We have to give it a chance. If it just ends up doing the same old thing then nothing will change. But we have enough evidence from what we’ve been doing with children and families over the past decade or so and what we are beginning to see is something better emerging and we need to build on that.”