Associate feature: The case for prevention

“Scotland did not go into the COVID-19 pandemic fighting fit.”

That’s the pithy analysis of ten leading charities who’ve long monitored and sought to improve the health of the nation. 

The British Heart Foundation, Cancer Research UK, Diabetes Scotland, the Stroke Association, the British Lung Foundation, ASH Scotland, Obesity Action Scotland, Scottish Health Action on Alcohol Problems and Alcohol Focus Scotland – each organisation may have its specialisation, but together they represent expertise on practically the entire human body and its afflictions.

And all of these charities have now come together to prompt a discussion of what their work – and our bodies – all have in common, and how the health of the nation as a whole could be improved, beyond the pandemic recovery.

In a new paper they make a renewed case for action on preventing the diseases that we have come so grimly used to referring to as ‘underlying conditions’. Through “bold” policy interventions, they argue, Scots could begin to live longer, healthier lives. 

“Urgent action is needed to address the societal factors that are affecting the health of people across Scotland’s communities,” the charities say. 

It’s long been the case that non-communicable diseases (NCDs) such as heart disease, cancer, stroke, chronic respiratory diseases and diabetes, are the leading cause of mortality in Scotland. These diseases, the charities calculate, are responsible for almost 39,000 deaths every year. That’s more than two thirds of all deaths. 

And in terms of healthy life expectancy – the years of good health someone can expect to live on average – Scotland lags behind the rest of the UK and most of Western Europe, with a healthy life expectancy of just 62.3 years. 

The prevalence of these diseases in Scottish society has been a cause of widespread concern for a long time. But the unforeseen impact of COVID-19 has highlighted in a new and tragically unambiguous way the need to improve health and resilience at a population level.

“The virus initially infects the respiratory system, but the most common underlying health conditions in those who die are cardiovascular,” wrote Professor James Leiper, the associate medical director for research at the British Heart Foundation (BHF) in Holyrood in July. 

But in pre-COVID times, it comes as a stark realisation, a large number of Scotland’s deaths were classed as ‘preventable’. That’s not to say that more lives could be saved with emergency medical intervention, rather it’s a way of describing the longer-term story. Over the course of a lifetime, what we are each exposed to in our environments, the choices we make and the scenarios we find ourselves in, these hugely influence our health outcomes. 

In other words: it’s about diet, smoking and drinking.

It’s not about individual responsibility, it’s more to do with the environment that we all live in"

National Records of Scotland estimate that around 14,000 deaths a year in Scotland are preventable through public health action. 

This not only highlights the power of good policy aimed at preventing diseases, but also shows quite how much avoidable strain the NHS is taking, says Jonathan Roden, policy officer at BHF. 

“I think the COVID-19 pandemic has given all of us a wake-up call about the value of the NHS and the important role it plays in our society,” Roden tells Holyrood.

“One of the purposes behind this paper is to make sure that the prevention of disease isn’t forgotten amongst all that.

“The use of tobacco and alcohol and the impact of overweight and obesity have each been estimated to cost Scotland’s NHS hundreds of millions of pounds a year. 

“Emerging from the COVID-19 crisis, one of the best ways that the Scottish Parliament can support and thank the NHS is to help relieve that pressure by taking action on the things that we know increase levels of the NCDs that are the cause of more than half of deaths in Scotland,” he says.

The importance of taking a preventative approach won’t come as news to law makers in Scotland, something the paper recognises. 

“The Scottish Parliament has led the way in bold, population-level public health interventions such as the smoking ban and the minimum unit price for alcohol, and it is crucial for the health of the nation that this is continued,” the charities say. 

The ambition laid out by the Scottish Government’s Tobacco-Free Generation strategy to have under five per cent of the population smoking by 2034 is also commended. 

But, as with many other areas of government business, the pandemic has swept away much of what was planned for the remainder of this parliamentary term. 

In June, the Scottish Government announced that it was “pausing” a new bill aimed at placing restrictions on the promotion of junk food through multi-buy offers and certain types of advertising.

Joe FitzPatrick, the minister for public health, said at the time that the Scottish Government remains “fully committed to restricting the promotion and marketing of foods high in fat, sugar or salt where they are sold to the public and will seek to progress this measure as soon as it is possible to do so.”

He added: “Pausing the introduction of the bill provides us with an opportunity to take stock, take into account the impact of the COVID-19 lockdown, including on people’s diet and healthy weight.”

In Scotland, nearly 30 per cent of adults and 13 per cent of children are obese, according to Scottish Government statistics.

A spokesperson for Diabetes UK told Holyrood that it is a “pressing health issue”, with obesity accounting for 85 per cent of a person’s risk in developing type two diabetes. 

“Type two diabetes can be prevented in more than half of all cases, but governments need to do more to support people to be healthy by taking action to change the environments we live in,” they said.

The charities all agree that it is “crucial” that the restricting food promotions bill be reintroduced in parliament as soon as possible. 

We know that if you live in a more deprived community, you’re more likely to smoke, you’re more likely to drink at a harmful level and you’re more likely to be overweight or obese"

They are also hoping that the Scottish Government delivers on its commitment to consult on controlling alcohol marketing before the end of this parliamentary term.

Similarly, the government needs to take further action towards meeting its targets under the Tobacco-Free Generation plans, the paper says.

Cancer Research UK estimated in February that the Scottish Government would miss the target by as much as 16 years if current trends aren’t changed. The charities suggest a new mass media campaign, as well as the more forthright promotion of smoking cessation services in the NHS as possible solutions. 

COVID-19 has provided a painful and all-too-clear illustration of how economic inequality leads to health inequalities, something the charities say must be factored into any preventative approach taken by government. 

Put simply, BHF’s Roden says: “We know that if you live in a more deprived community, you’re more likely to smoke, you’re more likely to drink at a harmful level and you’re more likely to be overweight or obese. 

“There’s a lot of research on this and we know that, for example, more deprived communities are more likely to have a higher concentration of takeaway outlets and less likely to have fresh food available to them. 

“Overarching all the calls in the paper is a call to say it’s not about individual responsibility, it’s more to do with the environment that we all live in,” he adds. 

This can be seen in the recently released Scottish Stroke Care Audit, the annual report on the state of stroke in Scotland. 

It flags the variation in average age for people having strokes in Scotland depending on where they live, with NHS Greater Glasgow and Clyde and NHS Lanarkshire in particular seeing more younger people having strokes.

The Stroke Association points out that these are also the health boards with higher numbers of patients in the two most deprived Scottish Index of Multiple Deprivation categories, with around 60 per cent of stroke cases within the most deprived categories.

More research is needed, too, on how racial inequalities play into this dynamic, the charities say. Better publicly available health data on minority ethnic groups would be an essential first step, according to the paper. 

Heading into May 2021’s Scottish election, the charities are urging all parties to reignite the discussion that was under way before the pandemic struck and seek to further the work, as Cancer Research UK puts it, to “support people to live healthy lives by changing the environments that we all live in”.

Roden from BHF wants to remind all political parties of the power that they have to really make a difference. 

He says: “There are a number of levers that the Scottish Parliament and Scottish Government can use to improve the lives and the health of all of Scotland’s communities. 

“We know that the best way to create impact and to improve public health, especially in our most deprived communities, is to change the environment that we know influences the levels of tobacco and alcohol use and the levels of overweight and obesity that we see in society.” 

This piece was sponsored by British Heart Foundation Scotland