Targeting prevention - a roundtable discussion on public health
Smoking, drinking, physical inactivity and poor diet are all behaviours which increase your risk of disease. This is fairly well known, but shifting these behaviours remains a challenge.
Indeed, 75 per cent of premature deaths in Scotland in 2013 were from non-communicable diseases (NCDs) – those chronic conditions which are non-infectious but long-lasting, including cardio-vascular disease, diabetes, cancer and chronic respiratory illnesses.
Preventing the most preventable diseases was the topic of Holyrood’s recent roundtable event in association with the British Heart Foundation, which brought together some of the country’s top public health academics with leading lights of the third sector.
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NCDs are a global problem. In 2012 the World Health Organisation (WHO) released a global framework on prevention and control of the diseases which included recommended targets on tobacco, physical activity, alcohol and salt to bring about a 25 per cent reduction in mortality by 2025.
Last year, however, WHO members conceded progress towards the targets had been too slow.
Researcher Joshua Bird produced a report for the British Heart Foundation on the framework, and this provided the backdrop for the discussion.
The obvious question in a Scottish context is whether these targets are realistic, and whether the Scottish Government can meet them.
Professor Linda Bauld, deputy director of the Centre for Tobacco and Alcohol Studies pointed to the national target for smoking prevention, five per cent of smokers by 2034, a more ambitious target than the WHO equivalent.
However, former Chief Medical Officer Sir Harry Burns said: “There are things the Scottish Government can’t control that are very important. One of my particular concerns is benefits policy. People are really struggling. If people are struggling to be able to buy food and so on then we’re not going to change what’s going on in nutrition in those particular groups.”
Professor of Public Health Nutrition Annie Anderson said the Government could exert more control by taking a tougher position with retail and marketing. She gave an example of an obese woman she had met in a clinic. “She said it’s really hard. ‘I went into the local shop it was five packets of crisps for a pound. Why wouldn’t I buy that?’”
Harry Burns replied: “Sure. The question is would she spend her pound on five bags of crisps or spend it on broccoli? The choices people make come down to more than just the cost of things.”
New British Heart Foundation Director of Scotland James Cant said First Minister Nicola Sturgeon’s ambition and renewed focus on educational attainment could be “an opportunity to offer that holistic view,” adding: “And what we will have to do to close that education gap are exactly the same things we need to do to close the health gap as well.”
But how can inequality be tackled collectively without entering into “the more superficial political arguments around how it is we divide up our resources?” asked Scotland national director at Diabetes UK Jane-Claire Judson. “We need to start looking at a more integrated way of influencing those issues.”
Hypertension specialist Professor Tom MacDonald said the validity of research was “dubious” because socially deprived and elderly people did not take part. Studies were of “nice middle-aged people interested in their health”, he said. Interventions could be tested on a massive scale by the NHS in Scotland, he argued.
Linda Bauld said tobacco provides an example of where the Scottish Government could use “the four Ps” – product, place, price and promotion – to act at a population level.
“We’ve done it for tobacco but they sure haven’t done it for food or alcohol, although they’re trying with minimum unit pricing,” she said.
But minimum unit pricing is being challenged through the courts by the drinks industry. Can the industry really be brought into the prevention discussion?
Jane-Claire Judson said the experience of having a formal relationship with Tesco as ‘charity of the year’ gave Diabetes UK an insight into the way supermarkets collect data, which it used to lobby for a traffic light system of food labelling.
“It’s been a bit of a journey for all the charities involved in that,” she said. Supermarkets might avoid politicised confrontations, but they’d be more likely to come to a roundtable event, she suggested.
Annie Anderson pointed out retailers walked away from a roundtable discussion over possible standards in food marketing.
Linda Bauld suggested non-government organisations (NGOs) can act as a bridge between commercial interests and government. “Commercial actors tend to get in the way of effective public health policy, but NGOs, including Cancer Research UK, have really important partnerships with some of those commercial actors to reach those communities they need to reach around health behaviours, and also because of the fundraising aspect.”
However, further limits on marketing would be a start, she agreed.
Scottish Government Senior Medical Officer Dr Duncan McCormick said lessons might be learned from a recent ‘fat tax’ in Denmark, which was repealed only a year after it had been introduced. Many countries have successfully introduced a tax on sugar, though, it was pointed out.
Meanwhile on salt, Annie Anderson said: “In Scotland our salt intake has not gone down. In England it has. Our sodium measurements are bad news. We’ve got reformulation across the world, and we don’t know why it’s not gone down,” she said.
Harry Burns pointed to the Early Years Collaborative (EYC) as an example of where a big aspiration can lead to policy shifts by securing high-level buy-in. “The fact is you have to tackle all of these things, and I think the way to sell this to a politician is to give them the high-level message and say ‘do you want to see what makes this work in practice?’”
Acting director for Scotland of Breast Cancer Now, Eluned Hughes, said advocating incremental change can help. “Then we can get people to the table, because we’re not asking too much, but gradually changing rather than coming in full sails with a full marketing ban or sports sponsorship.”
Jane-Claire Judson said incremental change must still match ambition. “You can’t have big change without incremental change, but you can’t have incremental change with no big goal. So how do we get to a place where we can have those conversations?” she asked. But Annie Anderson said incremental change wasn’t happening. “We’ve had loads of different approaches and policies and we’re getting nowhere,” she suggested.
Are government approaches really joined up? The BHF, said James Cant, will move away from focusing on individual illnesses to look at NCDs as a whole. He suggested government departments do the same. “Government is condemned to perpetual silos, and I can say that as a former civil servant. It’s never by design. I always compare silos to weeds in the garden, they just grow of their own accord and have to be continually addressed,” he said.
Harry Burns replied the Scottish Government’s departments are more joined up than at Westminster. “What I keep saying is I’m doing more work for the Scottish Government now than I did when I got a pay packet, and it’s communities, it’s justice, it’s economic development. They’re all thinking cross-government.”
The Scottish Government’s current public health review is looking at leadership in public health and “how to increase collaboration across departments”, according to Duncan McCormick.
Charities too, tend to fight their own corner, said Jane-Claire Judson, adding the onus was to go into conversations with an open agenda. “Because quite often the government asks the third sector to work in partnership in a way they don’t expect other bits of society to work together.”
If the EYC is an example of collaboration, Kirsty Yanik, Information Manager at Alzheimer’s Scotland asked whether adults – people in their 30s and 40s – could also be effectively targeted for public health interventions. The academics in the room agreed behaviour changes at all ages could be effective.
Yanik, Head of Scotland for Bowel Cancer UK, Emma Anderson and Andrea Cail, Scottish director of the Stroke Association agreed interventions were more effective when people had experienced the condition in their family already, but information needed to be effective.
Annie Anderson said education interventions can only go so far but the bigger picture is “what society supports and facilitates the individual to do.”
Tom MacDonald suggested improving the built environment would lead to healthier lives, and New York was raised by Harry Burns and Jane-Claire Judson as an example of where strong leadership on infrastructure like cyclepaths and water had improved public health. Annie Anderson said the culture of medicalisation could be met with prescribing preventative solutions like pedometers.
Individual and societal responsibilities should also be encouraged, suggested James Cant: “There has to be ‘you love the NHS, what are you as an individual trying to do to make sure you’re not part of the thing that’s breaking it?’” Emma Anderson said the NHS had an unhealthy workforce because of the strains on the system.
Meanwhile Tom MacDonald pleaded for NHS data to be made available to researchers. “It’s absolutely welded shut. We need to free up NHS data for the benefit of NHS patients. This is not people trying to find out who’s got cancer so we can call in their loans, it’s doctors like me trying to improve healthcare,” he said.
The solutions to shifting the public health agenda, it was agreed, have to be bottom-up. The First Minister, it was suggested, can be bold if presented with solutions from communities and the third sector to meet her own commitments to tackle inequality.
“We can’t just expect government to think of a great idea, or the third sector or researchers to think of a great idea. There’s stuff happening at grassroots level,” said Kirsty Yanik, pointing to how the organic growth of initiatives like the ice bucket challenge became global movements.
Walking groups organised at a grassroots level were cited by Harry Burns and Andrea Cail, and Jane-Claire Judson used the example of ‘roller derby’ – a sport which has enabled women previously excluded from physical activity to create an active community.
While the WHO targets, like other targets on obesity and salt in Scotland can provide a platform to unite third sector voices under a common cause, the focus must remain on people, it was agreed.
“Reports and goals aren’t for individual consumption. People responsible for implementing public health policy have to frame those in a way that gives real meaning for people out there,” said Annie Anderson.
On top of that, Duncan McCormick suggested more prevention targets could be included in the annual NHS performance HEAT targets too.
Leadership can come from all levels though. “Some of the leaders I have found are living in the poorest circumstances you can imagine,” said Harry Burns. The small-mindedness of middle management would have to be challenged, he said. “It comes back to government being brave, and everyone being brave. Stand up and bloody well do it, and gradually you’ll get a movement developing. If the First Minister’s at the head of that, great. My experience is politicians like success, so if you give them a success they’ll back it.”
James Cant drew the conversation to a close by recognising the agreement in the room for the need for a dual approach of a national framework combined with local activity.
“Our responsibility is to champion that best practice and those people at every opportunity, to build that jigsaw around the country,” he said.