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Chapter 1

The Director of Public Health says…

I publish a report on the health of the population of Greater Glasgow and Clyde every two years and this year I wish to start with some personal reflections on the challenges of improving health in these turbulent times. My main aim for the report is that it identifies the actions and directions that we need to take to improve health. I cannot stress too highly that despite improvements in recent years, too many people in Greater Glasgow and Clyde are still too sick at too early an age. This is not good for any of us and it requires our collective effort to make a difference.

My previous report called for debate and I am now calling for new ways of thinking and also for renewed conviction on the need for action to improve our health. In the midst of a world recession, national elections and the preparation for the London Olympics and the Glasgow Commonwealth Games, I want this report to be my manifesto for improving health and wellbeing over the next two years. I want this report to encourage all public and private sector organisations to step up to the challenges outlined in this report. I want it to reaffirm the
importance of addressing health inequalities and of supporting the most vulnerable in our population if we are to create vibrant successful cities, towns and communities.

The report sets out some new public health priorities for the Greater Glasgow & Clyde area, as well as reiterating priorities in my previous report for the period 2007 to 2009, around alcohol, obesity and early years. In this overview, I will discuss our approach to health inequalities, the need to focus on early years and the urgent need to take tough action on alcohol related problems. I want to encourage some different ways of thinking about the complex problems that confront us, for example through the work of the Glasgow Centre for Population Health and the work of Professor Phil Hanlon and colleagues at the University of Glasgow.

It is vital that we listen to communities and individuals about their experience of health and how they think their health could be improved. The second chapter of the report therefore seeks to reflect the voices of people in Greater Glasgow and Clyde. This information comes from a large interview survey of health and well-being and also from video interviews with a range of people as they go about their normal lives.

Trends in health – Some of the good news

A recurring theme of the report is the ever present and widening contrasts in health amongst different groups in the population but first I want to remind readers of some of the improvements in health in recent years. It is exciting to see how many of the recommended actions in my
previous report have been progressed. Appendix 1 describes these in more detail.

In many ways, people living in Greater Glasgow and Clyde have never been healthier. Deaths from coronary heart disease have significantly reduced over the last ten years. The overall age and sex standardised Coronary Heart Disease mortality fell from 198 per 100,000 populations in 1998 to 122 per 100,000 in 2007, a reduction of almost 40%. Rates of premature mortality from all causes reduced by 43% over the same ten-year period. These reductions are similar to those in countries such as Finland, with their widely publicised declines. This reduction is through a mixture of improved treatment and better prevention. The chapter on ensuring equitable access to preventive services describes initiatives designed to increase uptake of health checks and other preventive services.

Cancer survival is getting better - for example five-year survival rates for breast cancer have increased from 64% for those diagnosed in 1980-84 to 84% in 2000-04. Survival from childhood leukaemia has improved dramatically due to more effective treatment. Large improvements in survival are also seen for cancers of the colon and rectum, with 55% of patients now surviving at least five years compared with 35% of those diagnosed in 1980-84.

Over the last 20 years the NHS National Cervical Screening Programme has resulted in a halving of cervical cancer rates. The newly introduced Human Papilloma Virus (HPV) immunisation programme will protect against strains of HPV that account for 70% of cervical
cancer and this could potentially save up to 165 lives in NHSGGC over a decade.(1) High uptake rates are being achieved for HPV vaccination through effective publicity and information and accessible services. The programme is provided not just through schools and general practices but also in leisure centres and city centre locations to improve uptake.

Inequalities in Health – much still to be done

Despite progress, our health challenges remain considerable. Social disparities and poverty continue to harm and kill many in our population, as do the experiences of discrimination faced by different groups. Greater Glasgow and Clyde still experiences some of the widest variations
in health between the affluent and poor in society.

A recent Journal of Public Health quoted Confucius as saying a leader should “concern himself with uneven distribution and not scarcity”.(2) Such ancient words of wisdom continue to be true here in Greater Glasgow and Clyde. It is well known that the larger the difference in income between the affluent and more deprived people in a community, the higher the level of almost every modern social, environmental and health problem; from infant mortality rates to levels of educational attainment; from rates of mental illness or levels of obesity to the size of prison populations; from rates of illegal drug use to violence.

Effective solutions to the problem of inequality and poor health will require societal change and involvement of many different agencies, policy makers, economists and politicians. My own joint role as Director of Public Health of NHS Greater Glasgow and Clyde and of Glasgow
City Council provides valuable opportunities for public health leadership in a local authority setting. This type of joint role is well developed in England but less so in Scotland. My own early experience confirms to me the value of being part of a local authority, serving on its corporate
management team, and working with elected members. I would like to see this model extended to our other local authorities involving colleagues in public health.

There have been major changes since the previous report, most notably the recent economic crisis. Margaret Chan, the director of WHO, in her response to the impact of the global financial crisis argues that “equitable access to health care and greater equity in health outcomes is
fundamental to a well-functioning economy”.(4) She concludes that equitable outcomes should be the principal measure of how we, as a civilized society are making progress. My report includes a chapter on the potential impact of the economic situation on health in Greater
Glasgow and Clyde.

We have to think where the current economic climate is likely to take us. For example, it could lead to more unhealthy diets due to cost issues or to increased alcohol consumption due to stress. The potential impact of the recession on unemployment, with its adverse effects on
health, is described in the report. However, experience from previous recessions would tell us that there are also opportunities in the current economic climate.(5) Could this be a chance to: - reduce some of our income inequalities, which we know drive health inequalities; - reduce
some of the consumerism that has been shown to make so many of us unhappy;(6) - encourage more active travel? There is research suggesting that recessions can lead people to engage in fewer unhealthy activities and to spend more time in health-promoting activities such as walking instead of driving.(5) As Rahm Emanuel, President Obama’s chief of staff, said: “You never want a serious crisis to go to waste”.(7)

The risk is the young will be hit the hardest. Recent reports show record numbers of young people who are not in school, further education, training or working. They have no employment experience and they have grown up used to easy access to credit. If young people fail to find employment when they leave education or training, they can carry this scar throughout their lives. The media is reporting fears of another lost generation and I would say they are right to worry. Danny Dorling, the professor of geography from the University of Sheffield, has warned
that if the current recession plays out like those of the 70s, 80s and 90s, the UK could see mass levels of youth unemployment.(8) Martina Milburn, chief executive of youth charity The Prince’s Trust, said: “It is more important than ever that we support those with fewest qualifications before they become a lost generation.” (8) I am encouraged by recent discussions of the high priority being given to preventing unemployment in young people by community planning partners.

Agencies in Greater Glasgow and Clyde must work to mitigate the effects of the recession on health at a time when their budgets will also be constrained. Defending budgets for activities which promote public health and well-being, particularly those which could narrow the health
gap may become more difficult. This would be a very short-sighted approach and would fuel more problems for that potential scarred and lost generation of young people. Many of the initiatives discussed in my previous report and progressed over the past two years around
employability, financial inclusion services, drug and alcohol services and family support are now more important than ever. As we see some signs that the recession is reducing, the public sector in Greater Glasgow and Clyde must do all that it can to prevent youth unemployment
and further widening of the inequities in society even if this is at the expense of some overall economic growth.

Public health advocates have traditionally argued for levelling up of the circumstances of the poor to those of the rich in order to address inequalities but the experience of the recession and our growing concerns about climate change show that this strategy is unsustainable. It would require consumption of more resources than are available globally. We all need to change the way we live and not be fearful that this will be a bad thing – more equal societies are more content societies.

Iona Heath, a London GP who writes in the BMJ, has said we would not be able to tackle health inequalities without paying attention to the rich as well as the poor.(9) Muir Gray has recently advocated in the same journal that the medical profession needs to lead the revolution but to recognise that it could be very radical. He asks: ‘Will the profession for example accept or even campaign for a 5% reduction in the salaries and pensions of its senior members so that more resources are available for tests and treatments of high value?’(10) I wonder how many of us would be willing to campaign for salary reductions for the overall benefit of society, yet we might actually be “better off” if this happened.

The International Futures Forum, a non-profit organisation that seeks to support a transformative response to complex challenges in today’s world, has encouraged us to think about three horizons when we consider radical change. The first horizon is immediate as it represents the responses to the immediate problem that are required in the short term but will not solve the problems. The third horizon represents our vision of long-term sustainable change.  The second horizon is the bridge from the first to the third horizons i.e. it is a strategy for transition. To achieve change, work has to begin on all three horizons now.

During this time of change we have an opportunity to develop a vision for a different Greater Glasgow and Clyde with a more equal and compassionate society, a more sustainable way of living with a greater sense of community, a society in which it is easier to cycle than get in
your car and where we produce more of our own food. To quote Margaret Chan again, she has stated that blind faith in economic growth and gain as the cure-for-all has been misplaced.(11) So we should plan now to ensure that economic recovery comes about in a way that will support equality and sustainability.

Health behaviours – not just telling people what to do

Despite some media criticisms of my previous report being too “nanny state”, I remain an advocate for stronger national and local government roles in encouraging healthy choices to improve health. Ideally we want a responsible society that makes healthy choices but many people do not have real choices due to other factors in their lives – poverty, violence, access to good food, consumerism or inappropriate work/life balance. In the previous report I advocated removing unhealthy snacks from our public sector facilities including hospitals and leisure
centres and much progress has been made in these areas. We need considerably more progress in making it easier and safer for people to get out of their cars and onto bikes or public transport and walking. London has recently initiated a scheme to help fearful cyclists onto
the city streets. People who have not previously commuted by bike are accompanied around backstreets by cycling guides. In consultation on the recent Glasgow City Health Commission report, young people suggested regular “car free” days in the city with free public transport
and the chance also to try out cycling round the city. We need to be much more committed to making cycling a mainstream form of personal transport when only about two percent of all journeys in the UK involve a bike. This will require strong civic leadership and commitment as well as more of us to lead by example. Immediate actions required are discussed further in the chapter on physical activity.

As stated in my previous report, Greater Glasgow and Clyde has a drink problem. Whichever measure we use of consumption, health effects or crime and social effects, it is clear that this is a major problem in our population that affects a great number of people (perhaps most people) across society. As stated by McKee this should come as no surprise as consumption of alcohol is driven by price, availability and marketing and Greater Glasgow and Clyde, like the rest of the UK, is awash with low price, heavily marketed alcohol.(12) As discussed in the BMA’s recent report “Under the Influence”, the Alcohol Industry has increasingly sophisticated advertising and marketing techniques.(13) The response of the alcohol industry shows again that tackling powerful vested interest for the sake of public health is never straightforward or easy.(12) The Government’s move to minimum pricing is a policy that I personally strongly support and I would want to see further restrictions on advertising and marketing. A four-council summit on how to address our alcohol problems was held earlier this year. Renfrewshire, West Dunbartonshire, Inverclyde and Glasgow City Councils and Strathclyde Police are all committed to concerted
action. The overwhelming view of professionals and local communities is that this is a problem that is getting worse and that they want tough action around licensing as well as education and effective services.

I have had the privilege of being elected the convener of the Glasgow City Licensing Forum and I intend to work within the Forum and with local licensing boards on these issues. While I welcome the objective to promote public health in the new licensing legislation and the
additional limitations on access and special offers, I am aware also of its limitations for reducing consumption through price and availability. Licensing boards must listen to local communities and be willing to use the new licensing legislation as effectively as possible, not being put off
tough action through fear of being challenged. At this year’s National Licensing Conference, Kenny MacAskill, the Cabinet Secretary for Justice, stated that the government would support this approach. Progress in tackling Greater Glasgow and Clyde’s alcohol problem is discussed in more detail in a full chapter in this report.

Child health – the key to change

Despite many improvements in child health, some aspects of children’s health are not improving. For example, mental health problems are worryingly high in children and young people and recent surveys of school children in Renfrewshire, West Dunbartonshire and in Glasgow City showed high levels of mood disturbance and use of alcohol in young people.

I am in no doubt of the crucial, nurturing role of parents and good parenting within families as we reflect on these problems. There is growing evidence that not only extreme abuse and neglect profoundly affect a child’s brain and future well-being, but that much more common problems and poor parent-child attachment also have long term effects. The commitment to expanding our support for parents by the NHS and local authorities in this area is an important step in empowering parents in their crucial role.

We are only too aware of the high number of vulnerable families in our population - vulnerable because of lack of material resources, little informal support, poor experience of parenting or drug and alcohol addiction. The high level of need has meant that our thresholds for intervention are too high. By not intervening early enough or to a sufficient intensity, children can suffer developmental consequences. The consequences of limited and late intervention include educational failure, antisocial behaviour, crime and violence, and responding to these problems consumes increasing sums of public money. The most effective interventions to improve the lives and opportunities of vulnerable children will be delivered before they are three years old.

Children with persistent antisocial behaviour at aged ten cost society ten times as much as children without the disorder by age 28. The consequences of vulnerability in childhood are increased costs of health care, social care and education in childhood, and in adult life,
increased costs of crime and disorder, substance misuse, worklessness and intergenerational poverty. If we are to address this, considerably more priority and attention should be afforded to education, child health and support for families.

I have been working closely with Triple P International over the past year. This is a positive parenting programme that has a robust evidence-base of improved child behavioural outcomes.  Research studies of this programme demonstrate improved parental confidence and at a
population level, lower prevalence of child abuse. Implementing this programme across the population could be one of the keys to unlocking the true potential and life expectations of the next generation. We need a greater focus on implementing this programme and on working
with families to participate with the programme. This will require only modest additional resource but is dependent on leadership and commitment from all agencies and close working with families and voluntary sector groups.

Well-being in turbulent times

When I consider the complexity of the problems described in this report, it can seem that we are facing an ‘ingenuity gap’ - a gap between the problems we face and our capacity to respond effectively. This is one of the starting points of a research study led by Professor Phil
Hanlon at Glasgow University.a The team has used varieties of literatures and fieldwork to show that problems like obesity, inequalities, addictions and loss of well-being are influenced by ‘modern’ culture and are not being solved by interventions based on ‘modern’ thinking and practice. They argue that the mindset of the modern period (since the enlightenment and the industrial revolution) is itself intrinsic to the problem. It has brought many benefits but is now subject to diminishing returns and adverse effects. We have benefited from clean water,
vaccinations, better nutrition, faster transport, growing wealth and much else. But these gains offer little to combat problems like obesity where the driver seems to be modern society itself, with its consumer-based affluence and the eating and physical activity habits which go with
it. Take another example… because living conditions in modern societies have improved and people’s incomes have increased many-fold since the end of the war, economists predicted a commensurate rise in well-being. Yet since the 1970s well-being has been static. Evidence
suggests that increases in income, once past a threshold where basic needs are satisfied, produce diminishing returns in well-being. Yet this is not reflected in our daily lives, where most of us continue to pursue the accumulation of wealth, possessions and social status. The work
from Glasgow University begins to cast light on such self-defeating behaviour.

Existing health promotion and public health models and approaches focusing on either biological or structural issues are still relevant but we need additional focus on key dimensions of the human experience. Experience of recent years shows that the most intractable problems in health are not usually amenable to evidence-based professionally-led interventions but come from individuals and groups being inspired and motivated to make a difference. Hanlon et al’s work suggests that public agencies are ignoring the subjective and shared influences that shape health and well-being.b

[‘a’ and ‘b’ Phil Hanlon’s colleague in this work is Dr. Sandra Carlisle and his key collaborators are Dr. Andrew Lyon, Dr. David Reilly,
Dr. Margaret Hannah, Professor Carol Tannahill and Mr. Gregor Henderson.]

It is clear, therefore, that, if we are to confront successfully problems like addictions or obesity, transformational change will be needed. Much of our response is more about adaptation – we build bigger airline seats to hold heavier people and expand the methadone programme to reduce harm for increasing addicts. Yet the lesson of history is that we as human beings are capable of transformational change when necessity dictates. Consider Glasgow in 1820 when people fled from the land into one the world’s first industrialised cities. Men and women suffered much but, in time, they created the modern conurbation in which we now live. The Glasgow University team sees a parallel with the present. They argue that the twin threats of climate change and the imminent peaking in global oil production will change our society as profoundly as the industrial revolution changed lives during the 1820s. Limits to growth of carbon dioxide, energy use or money supply will change profoundly the way we work, play, organise services, feed ourselves, commute and much more. These changes in how we live will be profound but, if health and well-being are to improve, we will also need inner change – a change in
consciousness.

Hanlon and his colleagues will be launching a website early in 2010 to stimulate debate about these ideas. They believe the Glasgow area is particularly vulnerable to the impending changes but their hope is that if we act soon enough we can not so much solve as outgrow some of our seemingly intractable problems. The downside of this message is that change is inevitable and imminent – and change can be painful. The upside is that we could create less inequality, less obesity, more cooperation and an enhanced sense of connection and well-being.

I intend to encourage our community planning partnerships to consider this work and to use it to
create the conditions conducive to positive change.

Pandemic Flu - lessons to be learnt

During recent months a great deal of public health effort has been devoted to managing the Influenza A (H1N1) pandemic. A major priority for public health in the coming months will be to deliver a well-planned vaccination programme for Influenza A (H1N1) as well as to respond to increasing numbers of people infected. Some readers may be surprised that a public health report contains so little about pandemic flu but my view is that while managing the pandemic effectively is vital, it is as important, if not more important, for population health that we continue
to work on the other priorities for improving health and preventing ill-health set out in this report.  (Appendix 2 shows where you can get further information on pandemic flu)

Many of the early lessons from the containment phase of the pandemic can be applied to other public health challenges. I have been impressed and encouraged by the way the staff in this organisation and in our partner organisations have been able to cope with the rapidly changing demands around Influenza A (H1N1) and to work flexibly in a committed and coordinated way.  It showed me that with a common purpose we can make a difference, we can adapt to new situations and we can support each other in our efforts.

My commitments

Priorities for action are described in each chapter of the report. The fact that health improvement is good for all aspects of a well-functioning society means that the priorities for action in this report are as relevant to all public sector agencies and to private business and enterprise as to the NHS.

I intend to build on the energy, creativity and commitment to protecting health shown by this organisation and its partner agencies in responding to Influenza A (H1N1) to take forward the priorities in this report.

Although agencies in Greater Glasgow and Clyde will be only too well aware of the stark statistics on health inequalities due to disadvantage, gender, age, ethnicity and disability, we need collectively to make sure that we truly take on the implications of this information in our
planning and in our service delivery. I personally undertake to continue to inform community planning partnerships of the level of need, the evidence for action and the tough decisions required to enact effective actions. I will use this report within our community planning structures
to set their agenda for the next two years and monitor the impact of the actions. I will hold up the mirror of evaluation on how successful we are being in reducing health inequality.

The interesting new thinking around integrative public health practice that includes consideration of key dimensions of the human experience in influencing health, as developed by Hanlon and colleagues, has greatly influenced me. I intend to raise these issues and the need to respond
and think differently in the many forums and groups that I lead or in which participate. I will continue to advocate evidence-based practice but to paraphrase a recent column by Dr Des Spence, a Glasgow GP writing in the BMJ, the time is right for more “ideas-based practice” and
I will try to create conditions to encourage this.(14)

Over the next two years I will explore the development of closer integration of public health roles with local authority teams based on my experience of a joint post in Glasgow City Council. I hope this may involve clinical directors in Community Health (and Care) Partnerships
(CH(C)Ps) and others with public health and health improvement roles in partnerships. I am leading a review of our health improvement function and will include this issue within it.  I call on all local authorities to join forces with the NHS in utilising the evidence of the costeffectiveness of Triple P and to prioritise the implementation of the programme even in the current financial climate. I will continue to work with the CH(C)Ps in taking forward the implementation and evaluation of the programme to evidence the improved outcomes
demonstrated in other countries.

In conclusion, the key messages I wish to convey are that the way we respond to the financial recession could profoundly influence our effectiveness in addressing health inequalities, that a clearer focus on the early years and parenting is crucial to improving health and well-being and that while we cannot absolve people of personal responsibility to eat well, be active or drink responsibly we must recognise the importance of structural, societal and legislative change to facilitate sustainable behavioural change.

The Director of Public Health report has a range of different audiences including the general public, students, campaigners, politicians, voluntary organisations, public sector agencies and experts in public health. This report has been written in a style which aims to take these different groups into account and we have followed the Scottish Accessible Information Forum guidelines to improve its accessibility for disabled people. The report is available in different formats. It is also summarised in Greater Glasgow and Clyde’s public-facing newspaper “Health News” which is widely distributed throughout the region and is also available to read or download on the
NHSGGC website.

I hope you enjoy reading this report and would be very pleased to receive feedback on its content, its presentation and its usefulness to inform future reports.

Linda de Caestecker
Director of Public Health
NHS Greater Glasgow and Clyde
Dalian House
PO Box 15327
350 St. Vincent Street
Glasgow
G3 8YU
Tel 0141 201 4620
Email [email protected]