Scotland’s independent think tank
Scotland’s independent think tank

Foundations for reform: system wide and preventative approaches – Paul Johnston

I have enjoyed reading the important contributions that have been made so far to the Reform Scotland discussion on NHS 2048. They set out areas for change that have resonance, from the potential of innovation, technology and AI, the scope for greater citizen empowerment and the necessity of work on leadership and culture.

My own experience of public service leadership in areas such as policing convinces me that reform is possible – delivering better services for the public in a more sustainable manner. However, to be successful, reform must be built on strong foundations.

There are two building blocks that provide a firm underpinning for the reform of the NHS. The first requires health and social care to be seen in the broader context of what makes for health and wellbeing. And the second is an intensification of work to get upstream – preventing problems and promoting good health alongside the necessary focus on responding to ill-health.

Our health is shaped by a complex network of factors, including social and economic factors, health behaviours, health services, and the places that we live and work. None of these operates in isolation. Excellent health services will support improved health and wellbeing of our population as a whole – but cannot bear all the responsibility for this. Tackling poverty impacts on health, as does the availability of good work, high quality education and childcare, affordable housing, addressing climate change, and tackling racism.

Scotland’s health challenges require collective focus and resolve. People in Scotland now die younger than in any other Western European country. People spend more of their lives in ill health. The gap in life expectancy between the poorest and the wealthiest is growing. We have seen great progress in the past but, at the moment, Scotland’s health is getting worse.

There are further challenges facing us too. The Scottish Burden of Disease Study forecasts a 21% increase in disease by 2043, as our population continues to age. Two thirds of this will be due to a rise in the numbers of cancer cases, cardiovascular disease, and neurological conditions. All these present a significant challenge to the long-term sustainability of the health and social care system.

In my first year as Chief Executive of Public Health Scotland, I have seen clearly that change is possible. A collective focus on prevention, particularly primary prevention, can stop problems from happening in the first place and help reduce demand on public services, including our health and social care system. I am encouraged by the preventative interventions that are already receiving substantial investment in areas such as the Scottish Child Payment, the expansion of Early Learning and Childcare and vital work to keep The Promise.

Within public health, vaccination and screening are two of the best examples of prevention in action. We can draw on a range of examples where we have been bold and innovative in tackling Scotland’s public health challenges through prevention. 

These include:

There is a growing body of economic evidence that supports the case for investing in public health interventions and prevention. A debate on the future of the NHS must include a focus on how collectively our public services – including national and local government, the NHS, businesses, communities, and individuals can achieve that increased focus on prevention and reverse current population health trends.

At a time of resource pressure, encouraging investment in primary prevention is challenging but the case remains compelling. For example, the IPPR suggest that £2.3 billion of health boards’ budgets in Scotland is being directed at responding to the impacts of poverty. The annual cost to the UK of obesity and overweight is estimated to be approx. £98 billion, with costs to the NHS of £19 billion. A concerted focus on these two areas alone has the potential to contribute significantly to reducing demand on our health system as well as having a positive social and economic impact.

An increased focus on prevention raises fundamental questions about how and where we invest already stretched resources and capacity where they will have the biggest impact. There are new ideas emerging which could, if adopted, fundamentally change our approach to delivering health care.

We must be bold and brave in the face of the health challenges we face. A focus on increasing prevention is increasingly gaining traction and it is important we look to shape these opportunities, particularly in reforming and modernising our public services.

Within Public Health Scotland we are using our evidence and insight to support decision makers in allocating resources in a way that will increasingly achieve upstream impact. Our vision is for a Scotland where everyone thrives. This involves preventing ill-health, promoting health and wellbeing, and tackling inequality.

We will play our part in securing a compelling and unifying vision for health and wellbeing in Scotland, built on the strong foundations of whole system reform and upstream interventions. Change is possible. Raising life expectancy, increasing wellbeing, and ensuring that our system of health and social care can support us all when we need it most is a mission that deserves a united focus across Scotland.

Paul Johnston is Chief Executive of Public Health Scotland

Find out more about Public Health Scotland’s approach to prevention here.

1 comment

  • Colin Millar

    I worked in social care for around 12 years, even undertaking well-being audits and assessments of people in receipt of social care and people with disabilities, long-term health conditions or impairments who were looking to access meaningful volunteering or paid work and completely concur with everything Paul states here. The system is silo’d and that means that we focus efforts on a single area or aspect then move our attention (and funding) to something else.

    A joined up approach to housing; health; employment; social care; finances and other aspects of our lives would yield far greater benefits to individuals, families, communities and the country as a whole.

    Unfortunately, we’re incapable or intransigent when it comes to reshaping approaches and bureaucracies do what they’re designed to do – continue to deliver consistently and avoid variation.

    A “National Care Service” will not remove these difficulties any more for social care or longer-term healthy life expectancy than the current model and systems do.

    “Well-being” has become a modern day cliché, a buzzword that hints at a whole system approach that doesn’t exist, even in our imaginations.

    It can be done – I know because I’ve been there and witnessed it – but it’s not being done.

    We need to understand what well-being is; then understand how we can consistently measure it; then examine the component parts; develop a coherent strategy for improving it’s constituent parts; act and then measure it again to make sure it’s working.

    In a small scale pilot, I personally witnessed it saving a lot of time and resources, financial and professional. It’s scalable and it’s achievable. We just need brave people to accept the challenge.

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