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" From July to September 2004 there were 42 MRSA episodes. From July to September 2009 there were 14 MRSA episodes "
Dr Alison McCallum

" Investing, on an industrial scale, in the evidence that they developed and helped inspire would deliver a more efficient health service and a healthier society
Dr Alison McCallum

" Without public health research, there would be no Director of Public Health Annual Report
Dr Alison McCallum

This is now...

The system wide approach to tackling health inequalities that we have adopted in Lothian requires us to provide high quality universal services. These are complemented by targeted interventions where the risks to health are greater and by tailoring interventions for individuals and families with multiple and complex needs. In this report, I have illustrated how this approach to service provision is already contributing to improvements in the health of the public in Lothian and to reductions in the gaps between the different populations that make up our society.

The themes and actions outlined in my annual reports contribute to the business plans of NHS Lothian and partner organisations, with achievement building on a year by year basis. Every year, I have focussed on some of the major threats to health and opportunities for improvement. I am particularly pleased about five development

  • NHS Lothian signed an agreement with the carbon trust to reduce our carbon footprint by 80% by the year 20501, won an award for the grey water laundry, reduced energy use by 2% per annum2 introduced a Bike to Work scheme and increased the availability of on site exercise facilities. There is also increasing interest in local procurement of food for the NHS as a way of reducing our carbon footprint and increasing our contribution to the local economy;
  • We redesigned the stop smoking services, increased their availability and ran a major publicity campaign. During 2008/9 the number of people using the service increased, from 3,785 in 2007/8, to over 5,400 and our success rate increased to 42%;
  • All of the hospital catering facilities have achieved the first step towards providing staff and visitors with healthy food - the 'Healthy Living Award'. We have some way to go before all of our food outlets meet the highest international standards for taste and nutrition but this is a great start;
  • Rates of Healthcare Associated Infection (HAI) continue to fall thanks to the combined efforts of staff, patients and visitors. We took the opportunity to develop a single infection control team to cover hospital and community settings including nursing homes. We have taken a systematic approach to implementing the evidence of what works, continue to work with the Scottish Patient Safety Programme and the international network led by the Institute of Healthcare Improvement; and
  • During 2008/9, the World Health Organisation identified our system wide approach to tackling health inequalities as a model of good practice. At more local level, East Lothian became an Equally Well test site. Our work with seldom heard groups also helped bring carers, patient advocates and minority ethnic groups together. We were successful in obtaining funding to expand Keep Well from Edinburgh to West Lothian and to help us meet the needs of people from the Gypsy Traveller and minority ethnic communities and to increase the level of support provided to prisoner's families and prison leavers.

This report has explored the interdependency between the economic and social health of society and the response of the health system to it.

[ Box 1 ] Public health research giants

Two Scottish giants of practical public health research died in 2009 and their legacy has had a lasting influence on the way we practice public health in Lothian. Professor Sir John Crofton introduced effective treatment for an important public health problem - tuberculosis. He was also instrumental in improving services for the prevention and treatment of homelessness and problems associated with alcohol and smoking. Professor Jerry Morris established the role of physical activity in reducing the risk of cardiovascular disease and helped establish the evidence base for a minimum income for healthy living. Investing, on an industrial scale, in the evidence that they developed and helped inspire would deliver a more efficient health service and a healthier society.

Looking Forward

So what does the future hold for health provision for the population of Lothian? A mutual NHS must have relationships based on trust, sustainability and shared goals. Our achievements to date and our understanding of how to tackle continuing challenges relies on the large body of public health research that underpins the work of the NHS in Lothian. By studying patterns of health and disease in populations we generate new knowledge that will improve health and reduce health inequalities. The role of research must be key to future programmes and developments to help identify inequalities in service provision and possible solutions, inform debate, measure success and provide input for further research.

Due to its nature it has always been more difficult to fund this type of research as the methods employed are complex and evidence of benefit takes longer to accumulate than it does for research into drug treatments for acute illnesses. Over recent years however, evidence of effective public health interventions has been accumulating. Undertaking and being an advocate for public health research and its implementation therefore, continues to be an essential part of the role of the Director of Public Health.

Public Health Research for the future:

When public finances are tight, public health research provides evidence to help guide decision making and expenditure. One example is the almost linear relationship between higher levels of benefit for families and lower infant mortality. The WHO report on the Social Determinants of Health 'Closing the gap in a generation'3 is full of such high quality evidence. The evidence in this report provides national and local governments with a framework designed to reduce current levels of distress, disability and premature death.

The future for public health research is in "closing the gap" between knowing what works, and delivering it effectively. Allocating resources to change the way services are organised and reducing barriers to participation for example, is significantly more likely to reduce inequalities in access to prevention than commonly-used standalone educational interventions. The challenge is to convince the public and members of the health service that the benefits of such interventions are real and can be realised.

Our public health research programme examines influences on health and health inequalities and interventions that might improve life in Lothian from bench to bedside to bus stop. During 2008/9 we published work on topics that included:

  • Advances in our understanding of the genetics of colorectal cancer;
  • Development of markers that can help assess severity and risk of chronic diseases like diabetes, cardiovascular and liver disease at an earlier stage;
  • Factors that make it more difficult for people to follow medical advice or take their medicine;
  • Measuring equity of access to prevention, treatment and care;
  • Trends in multi-resistant tuberculosis;
  • Improving the way we handle clusters of infection;
  • The impact of the smoking legislation on smoking cessation;
  • The health impact of green space; and
  • The health impact of transport policy.

The Chief Scientist Office research strategy Investing in Research, Improving Health4 sets out the way forward. The strategy has four aims: securing benefit; improving population health; valuing and investing in NHS research; and building and securing skills. Local public health academics, NHS staff and local residents were involved in developing the strategy and will help achieve its aims. It is particularly helpful that the section on Improving Population Health recognises the importance of linking records for research. Record linkage is a technical method of joining up individual level information from various sources in a secure and non-identifiable way. Research using record linkage is essential to our ability to understand patterns of health and disease in the population and to improve outcomes for patients. Over the coming years, we will be participating in local, national and international collaborations. These will help create and implement evidence required to make the health system more equitable. The results will also help us work more effectively with our partners to improve the lives and health of the people who live, work and receive care in Lothian.

The economic recession - a major challenge to health

Recession increases the likelihood that people will experience financial hardship, unemployment or both. The people likely to suffer the most in recession, including suffering adverse health effects, are those that remain unemployed in the long term. Previous analyses have shown that people who are most likely to become unemployed or economically inactive are: younger workers, older workers, those with low education levels and part time workers, of whom 80% are women. People with low skills, a disability or who are from an ethnic minority are also at high risk5.

Impact on Health Services

The adverse effects of increasing unemployment and financial stress are more likely to make people consult their GP and attend hospital. A Finnish study found an increase of 10% in hospital admission rates during recession, despite funding cuts6. This increase may not be solely attributable to the economic situation but does show the need to protect universal services during times of financial constraint in order to prevent increases in health inequalities. It is particularly important that the relationship between consultation length and quality of care, particularly in deprived areas, is not forgotten7.

GP consultations and hospital admission could rise due to:

  • Increased suicidal tendencies. Studies of trends in suicide mortality during recessions are less consistent but a recent large European study suggests that a 1% increase in unemployment is associated with 0.79% rise in both suicide and homicide8;
  • Increased use of alcohol and drugs. There is evidence that use of alcohol and drugs also increases in a recession. Individuals are more likely to binge drink, and a Scottish study has shown higher levels of consumption in unemployed men. Those in the most deprived SIMD quintile are 5 times more likely to die and 6 more likely to be admitted to hospital due to alcohol than those in the most affluent quintile9. So if the absolute level of deprivation increased then alcohol-related harm may increase in these communities;
  • Fear of crime and reduced physical exercise. Wider social impacts such as crime and fear of crime adversely affect mental health and may have wider impacts, for example people may walk or cycle less because of a fear of crime;
  • Increased mental health problems in children and adults. Children and young people living in poverty may suffer poor social outcomes and long term adverse impacts on their health. Studies from a previous recession in Finland found that economic hardship adversely impacted on parental mental health, marital interaction and parenting leading to poorer mental health in the children10,11.

The role of the NHS

The role of the NHS includes employment services, debt advice, housing services, health and social services particularly for mental health problems. The services likely to bring the greatest benefit to those with the highest needs should be prioritised.

NHS Lothian employs around 28,000 people, making it the biggest employer in Lothian; we spend millions of pounds purchasing goods and services from commercial suppliers and contracting with the third (voluntary) sector. We contribute to the development of a healthy local environment so that good employers want to be based in Lothian. The Bioquarter development is one example of this approach. The most obvious impact of the NHS on employment is in providing effective and timely prevention, treatment and care but the NHS also provides links to practical support. This includes: employment services through the Healthcare Academy and 'joined up for jobs' in Edinburgh; debt advice; a credit union; and vocational rehabilitation that helps people with physical and mental health problems to remain in work or to get back to work.

The accompanying CD-ROM provides an archive of previous public health reports and a detailed update of progress against action identified. This includes a copy of the annual reports for some of our major public health functions and a list of our research publications. As I conclude this report, I want to reinforce the key messages on the vital contribution of a mutual health service and the need to build trust in the future to our future health.

  • For individuals
  • For the NHS in Lothian
  • For all organisations in Lothian
  • For my own work as your independent Director of Public Health in Lothian.

Dr Alison McCallum
Director of Public Health and Health Policy
November 2009