Public Health in Scotland - Harry Burns

The Strategic Narrative

Challenges

• Demography

• Scotland’s public health

• Economic outlook

Life expectancy trendsLife expectancy: Scotland & other Western European Countries, 1851-2005

Source: Human Mortality Database

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

1851

-185

3

1855

-185

7

1859

-186

1

1863

-186

5

1867

-186

9

1871

-187

3

1875

-187

7

1879

-188

1

1883

-188

5

1887

-188

9

1891

-189

3

1895

-189

7

1899

-190

1

1903

-190

5

1907

-190

9

1911

-191

3

1915

-191

7

1919

-192

1

1923

-192

5

1927

-192

9

1931

-193

3

1935

-193

7

1939

-194

1

1943

-194

5

1947

-194

9

1951

-195

3

1955

-195

7

1959

-196

1

1963

-196

5

1967

-196

9

1971

-197

3

1975

-197

7

1979

-198

1

1983

-198

5

1987

-198

9

1991

-199

3

1995

-199

7

1999

-200

1

2003

-200

5

Portugal

Scotland

Life expectancy trendsLife expectancy: Scotland & other Western European Countries, 1940-2005

Source: Human Mortality Database

45.0

50.0

55.0

60.0

65.0

70.0

75.0

80.0

85.0

1940

-194

2

1942

-194

4

1944

-194

6

1946

-194

8

1948

-195

0

1950

-195

2

1952

-195

4

1954

-195

6

1956

-195

8

1958

-196

0

1960

-196

2

1962

-196

4

1964

-196

6

1966

-196

8

1968

-197

0

1970

-197

2

1972

-197

4

1974

-197

6

1976

-197

8

1978

-198

0

1980

-198

2

1982

-198

4

1984

-198

6

1986

-198

8

1988

-199

0

1990

-199

2

1992

-199

4

1994

-199

6

1996

-199

8

1998

-200

0

2000

-200

2

2002

-200

4

Portugal

Trends in male life expectancy: Scotland

Richest 20%

Poorest 20%

Public health in Scotland

Public health in Scotland-turning 5 decades of failure into

success!

Public health in Scotland-turning 5 decades of failure into

success-with some lessons from riots along the

way!

Health Deficits approach

• We focus on problems, needs and deficiencies • We design services to fill gaps and fix problems• We make people passive recipients of services• We do things to people rather than with them.

“.....expresses the extent to which one has a feeling of confidence that the stimuli deriving from one's internal and external environments in the course of living are structured, predictable and explicable, that one has the internal resources to meet the demands posed by these stimuli and, finally, that these demands are seen as challenges, worthy of investment and engagement..""

Sense of coherence....

Health Assets A health asset is any factor or resource

which enhances the ability of individuals, communities and populations to maintain their health and sustain wellbeing. The assets can operate…as protective and promoting factors to buffer against life’s stresses

Morgan and Ziglio 2009

Health

• Everyday experience tells us health is NOT a state

• It is the outcome of a set of processes which are continually at work as we interact with others and our external environment

Diagnosed disease

Underlying risk factors

Health improvement or life improvement?

• Health is a property which emerges in individuals living in a fair and civilised society.

• Individuals who live in such a society understand how it works, can manage the challenges they face and participate fully in the life of the community.

• Such individuals are likely to feel in control of their lives and are likely to be healthy and feel well.

Horst Rittel and Melvin Webber

Wicked ProblemsRittel and Webber 1973

There is no definitive formulation of a wicked problem. It is not clear when wicked problems are resolved Solutions to wicked problems are not true-or-false, but

better or worse. Every attempted solution to a wicked problem counts

significantly because it changes the problem. The planner has no right to be wrong (planners are liable

for the consequences of the actions they generate).

Tackling wicked problems – Australian style

Authoritative or collaborative strategies? Narrow or broad approach? Firm trajectory or innovative “hunches?” Organisational focus or cross organisation? Tight governance or “project review?” Regulation or persuasion?

Management of complex systemsManagement of complex systems

The importance of instability – “never waste a good crisis”

Order generating rules – develop a common vision of what you want the future to be

Emergence of solutions – accept that the outcome may not be exactly what you anticipate

Building on assets Economic assets

Government and the private sector Environmental assets

Local government, community Social networks as assets

Community, 3rd sector Personal sense of control

Community, 3rd sector

Places for people

Places for people?

Building on assets Economic assets

Government and the private sector Environmental assets

Local government, community Social networks as assets

Community, 3rd sector Personal sense of control

Community, 3rd sector

Relevance to people

Transforming lives

Prolonged, non judgemental relationship builds trust

Individual learns of alternative lifestyles Realises he is free to choose Supported while he realigns his life Supports others in turn Success lies in the quality of the interactions

between the individual and his supporters

Types of communication

Debate - winners and losers Discourse - persuasion Dialogue – joint pursuit of a

new insight

Types of communication

Who are you lookin’ at? Debate - winners and losers Discourse - persuasion Dialogue – joint pursuit of a

new insight

A common vision?

• A healthy society

• Low criminal conviction rate

• Low teenage pregnancy rate

• High educational attainment

• Economically active

Self-control gradient and adult outcomes

Moffitt T E et al. PNAS 2011;108:2693-2698

©2011 by National Academy of Sciences

Numbers to remember

• 700 per second – the numbers of new neuronal connections in babies

• 18 months – the age at which speech disparities begin to appear

• 90-100% - the chance of developmental delays when a child experiences 6/7 adverse experiences

• 3:1 – the odds of heart disease in adulthood when experiencing 7/8 adverse experiences

• £5-£10 – the amount returned in childhood for every £1 invested in early programmes

Developmental delay and adversity

Risk of heart disease and early adversity

Vocabulary and social class

Compassion

• Are we ready to plan for a compassionate society?

Jimmy Reid 1971

Rectorial Address “Let me right at the outset define what I mean by

alienation. It is the cry of men who feel themselves the victims of blind economic forces beyond their control. It's the frustration of ordinary people excluded from the processes of decision making. The feeling of despair and hopelessness that pervades people who feel with justification that they have no real say in shaping or determining their own destinies....”