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5. Afterword
We are lucky in Scotland that it is rarely
necessary for us as Directors of Public
Health to take concerns directly to
the public because our advice is being
disregarded. The current economic
climate, however, causes me some
concern. This is my third period of austerity
as a doctor. I was a junior doctor in the
1980s and a new consultant in London in
the 1990s. Careful analysis of the impact
of previous recessions on health and health
services in Scotland and in other countries
enables me to conclude that, managed
in line with the evidence from around
the globe, things will be really difficult for
between two and five years but they will
get better. Unfortunately, however, there are
some examples of policy and practice from
previous recessions at home and abroad
where evidence has been disregarded and
avoidable ill-health and death have resulted.
As a consequence, our aspiration to close
the gap within a generation is abandoned
and, instead, a generation has its choices
and life chances severely limited.
The NHS in Lothian has a good track
record of identifying and addressing
inequity in service provision but it does
so within a set of rules and policies that
are agreed nationally and internationally.
A health service that is free at the point of
use is the rational, equitable and evidencebased
approach to the challenge of
reducing inequalities in avoidable premature
death, disability and distress. The evidence
on the adverse effects of making people
pay for health services is well established.
This solution is often recommended as a
way of increasing revenue available and
reducing what is perceived as inappropriate
use of services. However, it reduces service
use among those with greater levels of need
and fewer resources, who already face the
greatest barriers to service use. The policy
has limited impact on the understandable
wish of patients to visit specialists or to
have the latest treatment, even treatments
that provide limited benefit. The ability
to afford prescribed medicines and other
treatments follows a similar pattern.
The introduction of payments to use health
services has been shown elsewhere to
increase healthcare inequalities. It would
also make it more difficult to change the
balance between primary and secondary
care and to increase the proportion of care
that is delivered in a planned rather than
an emergency setting as patients present
with more advanced disease or avoidable
complications. While the recession has
seen a disproportionate reduction in the
funding for many services focussed on the populations with increased levels of need,
developments associated with Keep Well
mean that we are much closer to providing
equitable services for gypsy travellers.
Vigilance and surveillance during hard
times are vital or essential services will be
unavailable when required. In Lothian, in
1982, there was an epidemic of Hepatitis B
among injecting drug users [1]. This followed
an acute shortage of legally available clean
needles and syringes. Medical and public
health advice to reduce the spread of
infection by making clean needles and
syringes available was rejected. This expert
advice also had an eye to the prevention
of future harm. In December 1981, the first
cases of HIV and AIDS were reported in
injecting drug users in the United States
and in December 1982, the first case of
mother to child transmission was reported.
Stored blood samples from one general
practice indicate that HIV became epidemic
in Edinburgh during late 1983 – early 84 [1],
two years after the cluster in the United
States. By the end of 1986, approximately
1500-2000 drug users in Lothian, mostly
young adults, were estimated to be infected
with HIV. The first 20 cases of mother to
child transmission were reported in 1984/5,
again two years after the cluster in the
United States.
This experience led to the development
of excellent services from which other
countries now learn. It is a recent example
of the long history of people in Lothian
developing effective ways of caring
for patients with chronic unglamorous
conditions that are difficult to manage.
Primary care is central to these efforts.
Additional evidence for opiate substitution
in the context of high quality primary
care in the care and reduction in the risk
of premature death were published in
2010 [2]. This adds to the evidence of the
effectiveness of methadone programmes
in reducing harm from illegal drug users
(systematic review). Unfortunately, because
opiate substitution is not the complete answer, some people consider it controversial
in a way that treatments for other conditions
are not. It is important that we maintain
levels of unmet need for health and social
care for this population and their families
at low levels. Cities in countries without
universal services including opiate
substitution, exchange of needles and
drug paraphernalia and practical support
face situations similar to Lothian in the
1980s but on a much larger scale [3].
Our experience of developing just and
equitable services and of the wider links
between health and justice will be examined
in more detail in my next report.
Drug misuse is not the only area
where the evidence-based interventions
are implemented more slowly than is
reasonable. There are other examples
where the type of intervention affects
how quickly evidence is implemented.
The evidence on how to provide effective
smoking cessation and alcohol intervention
services was first published over 20 years
ago. Unlike medicines, however, there
is no single agreed process for managing
the introduction of effective programmes,
and disinvestment in ineffective ones. It is
only over the last three years, since ring
fenced funding has been available, that
these evidence-based treatments have
been introduced as co-ordinated services
on a scale that reflects the level of need
in the population. Going forward, smoking
cessation and alcohol brief interventions
should be funded as mainstream services
at the level required to meet population
health needs. As two of our most effective
treatments their continuation will have a
significant impact on reducing premature
death in Lothian.
Investment in public health interventions
is often cut or rejected outright on the
basis that it takes a generation to see a
difference. This misleading language may
be used to justify inaction; it may take a
generation to see the full effect, but careful
research and rapid, rigorous evaluation
will often show evidence of benefit and harm at population level within a one to
two year period. ‘Support from the Start’,
the Equally Well test site in Lothian has
collected evidence of improvement in
the health and wellbeing of children and
families using various of different methods.
Together, these results reflect the findings
of large research studies and should help
us measure reduction in the risk of future
problems. We already have reliable estimates
of the benefit of investment in the early years
as each £1 produces a benefit equivalent
to £5-7 saving on interventions required
in older children and adults.
A helpful policy environment is important.
The report from 1997-1999 from one of my
predecessors, Dr Helen Zealley, noted that
30% of children in Lothian were living below
the poverty line. Since 10-20% of children’s
health is directly related to their social
circumstances, the passing of the Child
Poverty Act is a welcome step in the right
direction. Child poverty is much higher in
the UK than in our comparator countries.
Eradicating child poverty would have a
major and long lasting positive effect on
health and wellbeing in Lothian, among
adults as well as children. This is because it
would require: attention to helping everyone
achieve their potential; a commitment to
healthy places; employment that provides
a living wage; social protection throughout
life; universal healthcare; and action to
reduce the prevalence of the individual
risks to physical and mental health that
are associated with premature death [4].
Combining commitment to this goal
with careful evaluation would also
help us prioritise our use of resources,
focussing on tackling unmet need and
ability to benefit. We have much to teach
others about equitable treatment for
common chronic conditions, particularly
the role of primary care, but there is a
lot still to be done if we are to tackle the
excess burden of ill-health among our
most vulnerable parents, children and
young people. This is our chance to
improve our health, and our future.
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