Health, Social Care and Sport Committee

Meeting date: Tuesday, September 21, 2021

Official Report 689KB pdf

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Public Health Stakeholder Session

Our third and main agenda item is a round-table session with public health stakeholders that is intended to inform the committee’s future work programme discussions.

I welcome Professor Sir Harry Burns, professor of practice and a special adviser at the University of Strathclyde; Professor Sir Michael Marmot, professor of epidemiology at University College London and director of University College London Institute of Health Equity; and Professor Katherine Smith, professor of public health policy at the University of Strathclyde.

I will kick off and set the agenda for the meeting. We have called on you all to help inform us on where the major themes lie in public health and where the committee might want to focus its efforts in relation to scrutiny and adding value to what the previous committee did. We also want to look at the landscape more generally to help us to prioritise our work programme. Your advice on that is greatly appreciated.

I will come to each professor in turn and ask where you think the committee should focus its efforts in our scrutiny of the public health agenda and where we might be able to add value. I turn to Professor Katherine Smith first.

My particular expertise is in understanding how previous policy approaches to addressing health inequalities have worked and what has shaped those policies, and in understanding public views on health inequalities in the United Kingdom.

My main recommendation is to focus scrutiny on ensuring that the policy making processes to tackle public health problems are properly joined up with the range of other policy areas that we know impact on public health or the social determinants. The Scottish Government has recognised that for a very long time in relation to things such as having—[Inaudible.]—and jobs that shape people’s health, but it seems to have been difficult to join up policy making so that we think adequately about those links and how policy decisions in other areas impact on public health and vice versa.

There have been efforts recently on public health reforms in Scotland, but I would keep a close eye on those. Every time that such efforts do not work out well, we end up with what we call in public health a downstream drift, where even though policy makers know that what they are doing is not the most effective thing, they end up doing it because those are the policy levers over which they have control.

I have a shout out for the broadcasting staff. Professor Smith’s feed is quite jumpy. If we take off her video, would the sound, which is the most important part, improve? We were able to hear some of what she said, but the sound was quite jumpy. We will try to get that sorted out.

May I tell you a story about a mythical country that, for the purposes of this morning, I will call Norway? Some years ago, the Minister of Foreign Affairs there said, “I am a health minister, because what I do in my day job influences health. Every minister is a health minister, because what we do in our day jobs influences health.”

Then I had a phone call from an official in the ministry of health in Norway whom I knew well, and she said, “You know how you’ve been going round the world saying that our Minister of Foreign Affairs says he’s a health minister? He now is our health minister, and he’d like to meet you”, so I went to Norway to meet him. He now is or will be Prime Minister Jonas Støre—I am not saying that correctly.

The message that I presume he will take to the Prime Minister’s office is that what happens across the whole Government is key to public health, particularly for health inequalities. Yes, the healthcare system is important and yes, organised public health is important, but it is about what happens across the whole of Government. Indeed, in the “Build Back Fairer” report for England that I published in December 2020, and the one for Greater Manchester that I published in June 2021, I said that we need to put equity of health and wellbeing at the heart of all Government policy. In other words, it is a whole approach to health equity and to reducing health inequalities, and it should be at the heart of all Government policy.

There are discussions going on at this very moment about energy price rises because of a shortage of gas. I have heard little from Government ministers about the likely distributional impact of the prices. They will have a huge impact on health inequalities. If poor people have to pay more for their heating, and we have a cold winter, that will have an immediate impact on health inequality. Putting equity of health and wellbeing at the heart of all Government policy is key to public health and to reducing health inequalities.

I am very much in the same sort of seam as Sir Michael. When we talk about health, we tend to think about illness and the absence of health as being ill. I was a surgeon for many years and I gave up surgery because I wanted to understand how we create wellness as opposed to tackling illness.

Sir Michael is absolutely right that it is a broad agenda. Creating wellbeing is what we would call a complex adaptive system. The problem with policy is that politicians like to do a thing. They make policies on fatty foods, on smoking or on alcohol and so on. In fact, we create wellbeing through a range of things that are not typically achieved through top-down policy. You can facilitate the creation of wellbeing by policy but, to a large extent, wellbeing is created in the relationships that people have with one another.

I speak a lot about the way in which wellbeing is created through early life, in the way in which children are born and raised and so on. Creating an environment that allows children to feel safe and happy and as if they have the opportunity to do well in life is really what I would want my Government to be doing and supporting.

I will give an example of a conversation that I had with one person, although I have had similar conversations with many people. The guy in question, who is currently working in a good job, started off his adult life in prison. When I spoke to him about his experiences, he said, “My mum and dad fought like cat and dog, and I would always get the blame for the fighting—it was always me who was in trouble. When I went to school, if there was any trouble there, I got the blame for it. When I was out on the streets with my mates, if anything happened, I would get the blame for it. I eventually ended up in jail.”

What transformed that guy’s life was a prison officer who took the time to talk to him every day and to tell him that he was better than that—that he was a clever guy who could do things in life. Building a trusting relationship with someone allowed him to begin to value himself. He now has a full-time job and is paying taxes. He is living well, with a family and children, but he helps other people who are in that position.

I would like to see a society where the politicians helped to support a bottom-up approach to improving wellbeing. It is important that they go out and ask front-line staff what people need rather than tell them what they are going to get. Politicians love a policy that they can fly a flag for, but I think that we ought to be building relationships that support people who live in difficult circumstances. There are lots of examples of organisations that do that, and we need to support them.

That was helpful in enabling us to start to think about where our focus might lie. One theme that we want to ask you about is to do with life expectancy and the factors that are involved in that. Some of you have been involved in producing important reports on the subject. It is a hugely complex area, on which all of us have read many reports.

My colleagues have a number of questions on life expectancy. We will start with Evelyn Tweed.

My questions are about the moniker that Scotland has had as “the sick man of Europe”. Does that moniker still apply to Scotland?

To whom would you like to address that first?

Sir Harry, please.

It is not a term that I have ever recognised or supported. There is no question but that inequalities began to widen dramatically in Scotland in around the 1950s, which was the time when industry was collapsing and housing policy shifted to the creation of new towns, where folk did not feel that they belonged. We can point to social drivers that created widening inequality in life expectancy.

However, it is unhelpful to label ourselves in those terms because, if folk are told that, they just shrug their shoulders and say, “Well, that’s it—I’m going out for another beer. To hell with it!” That was the attitude in the conversations that I used to have with my patients, who would say, “Life’s not worth living. The booze is the only pleasure I’ve got in life, so I’m just going to keep drinking.” I heard people make that statement many times.

I do not think that we should label ourselves in that way. We can do a lot better, and we should begin to take action to improve things, but what action we should take is complex and not straightforward. It is not as straightforward as banning smoking in public places, which was important and a great step forward. Minimum pricing of alcohol has made a difference, too, but we need to get in and help people to feel more in control of their lives and to take positive decisions about their health. That is what we should focus on.

09:15  

Would any of the other panellists like to comment?

I am sorry—I did not hear the question very well. However, I heard Harry Burns very clearly, so I will guess the question from his response. Please tell me if I am wrong.

I am keen to work with Scottish colleagues, but we have been doing a lot of work in different parts of England. I can give you some statistics, but first of all I should say that Scotland is like England in this respect, only more so.

If we look at life expectancy by level of deprivation in the areas where people live, we can see that there is a gradient, with the least deprived having the longest life expectancy and the most deprived the shortest. As for regional differences in England, we find that they are tiny for the least deprived; in other words, it does not matter much where you live if you are rich, and I guess that the same would apply to Scotland, too. The more deprived the area in which you live, the bigger the disadvantage of living in, say, the north-east or the north-west compared to London. In fact, in the decade since 2010, life expectancy for the poorest 10 per cent improved in London and went down in every other England region. Things got worse for the poor—their health declined.

With regard to the north-east and the north-west, you could, as Harry Burns described with regard to the deindustrialisation of Scotland, look at the situation there and say that it is hopeless. You could say that, for someone growing up north of the Tyne or in Cheshire, Merseyside or parts of Greater Manchester, things are hopeless and the future looks grim. However, people in those regions are not taking that approach. We have been invited to each of the places that I have mentioned. We have been to Cheshire and Merseyside; yesterday we launched a commission in Lancashire and south Cumbria; we did a report for Greater Manchester; and we have been approached by the North of Tyne Combined Authority. They are saying, “This is not hopeless. We can improve the quality of the lives of those who live in these regions. It has to be a partnership and we have to work together, but we are not starting with the assumption that this is all hopeless.”

It is pretty grim to know that the health of poor people got worse over the past decade—indeed, it is quite an indictment of public policy—but the starting position is that things can be improved and a real difference can be made. It seems to me that that is absolutely right. In launching the commission yesterday evening in Lancashire and south Cumbria—a deprived area of the country with huge inequalities—we found that the starting position for local and regional government, the voluntary and community sector and business is, “We can make a real difference. We can work with our population to improve the quality of lives and health.” That has to be the starting position in every region of Scotland, too.

I ask Professor Smith to comment.

Is the feed working better now?

Yes, that is a lot better.

I agree with a lot of what has been said. There are different ways of thinking about Scotland’s relative performance on health and health inequalities. There are a lot of examples of places around Scotland to which we can look for inspiration, because things are going a bit better there; we can look at what people there have done. I would frame it in that way. The description of Scotland as the sick man of Europe is not a particularly helpful framing. Nonetheless, we need to recognise that there are issues that seem to be particularly bad in Scotland. Drug and alcohol-related deaths are particular issues on which Scotland needs to have a focus.

I support what my colleagues just articulated. A key issue is that we must think about how we have a public conversation about health inequalities, taking a bottom-up approach. We need to go beyond the voluntary sector and front-line services and have a conversation with members of the public about health inequalities and how we tackle them. That has been lacking from research into health inequalities. I am one of the few people I know who have tried to do research into what people think about health inequalities in the United Kingdom and Scotland. The research suggests that people are concerned about the issue and are supportive of policy proposals to tackle the social determinants of health, which should give us lots of reasons to be hopeful.

Do we need specific interventions in specific places or more system-wide interventions? For example, air pollution kills 2,500 Scots per year, according to Friends of the Earth Scotland. In my region, we have Scotland’s biggest polluter. In our papers, there is a focus on Glasgow, which is a unique example in Scotland, in that not only is it one of our major cities but it has a very large motorway running through its middle. There are particular issues in Glasgow with early deaths and so on. Does the panel think that we need specific, place-based interventions or wider system change on air pollution and other determinants of poor health?

I will bring in Professor Burns first.

There is no doubt that it can help to measure things such as air pollution, not just outside but in homes, schools and so on—and doing that has become much more important with the advent of Covid, which has made us interested in ventilation and so on.

However, I come back to the point that the major drivers of inequality and life expectancy in Scotland are not things such as heart attacks and cancers, but the wide differentials in deaths among young, working-age people due to things such as drugs, alcohol, suicide, violence and accidents. Yes, we can and should look at individual issues, and air pollution is an important aspect, but if we are to achieve success, we are going to have to support young people who get themselves into difficulties with drugs, alcohol and so on, because they are the ones who will die young as a result of being in those difficulties.

A study from the University of Glasgow some years ago showed that heart attack deaths were a relatively small contributor to health inequalities. The difference in death rates from drugs, alcohol, suicide and violence begins to shoot up in the teenage years. I am really keen that the Parliament should focus on the creation of wellbeing in families and on support for families in the early years. All the other things are important, but if we do not do the early-life stuff, the other things will have a relatively minor impact.

I will make three points. First, I talk to a lot of different disease-specific groups, and I was asked to talk to dentists about oral health. I showed them two graphs featuring the social gradient by deprivation. By classifying people by where they live and classifying where they live by deprivation, divided into deciles—10 per cent—you can see a gradient. I did not put labels on the Y axis—I did not say which diseases I was looking at. The gradients were identical. When I put the labels on, one was Covid-19 mortality, and the other was decayed, missing and filled teeth in children. The gradients were identical.

When I gave a talk to some heart disease people, I got a third graph, which I did not label either. It was for childhood obesity. The gradient was identical. We could focus on cardiovascular disease, oral health or Covid-19. Covid-19 is caused by a virus; dental caries are caused by diet and poor oral hygiene; and childhood obesity is caused by—well, your guess is as good as mine—but they all show identical social gradients. I could show you graphs of air pollution in schools in London, which have an identical gradient. The poorer the area of London, the higher the degree of air pollution in schools.

I am happy for the heart disease people to focus on childhood obesity, for the oral health people to focus on reducing dental caries and for the infectious disease people to focus on Covid-19, but we have to deal with the inequalities that underlie each of those specific conditions. That is the first thing to say.

It is not an either/or question. I recently reviewed Jeremy Farrar’s book, “Spike”, on Covid-19, Jeremy Farrar being the director of the Wellcome Trust and a member of the scientific advisory group for emergencies—SAGE. I think he mentioned inequalities once in the book, but I did not pan it because of that. It was a brilliant book; I enjoyed reading it, I learned a lot and I gave it a very positive review. However, I did comment. My approach is to deal with the inequalities; his approach is to deal with control of the virus. It is not either/or; it is both—we need both those approaches.

Turning to my second point, should we focus on particularly high-risk areas, or do we need something more general? In my 2010 English review, I coined the rather awkward phrase “proportionate universalism”. It was the classic British compromise. I was trying to deal with the classic Anglo-Saxon approach to social policy, which is to target the worst off, and the more Nordic approach, which is to have universalist policies. When Harry Burns was chief medical officer for Scotland, he said that he was all for Nordic universalist approaches. I was trying to bring the two together. When we accept that there is a gradient, if we focus only on the worst off, we miss most of the inequalities, which are not confined to the very worst off. We need effort that is proportionate to need—hence, proportionate universalism. I think that that is absolutely right. We need to improve air quality for everybody, to take that example, and we need to work harder in the most polluted areas.

The third thing that I wish to say, particularly in relation to air pollution, illustrates the more general point that we need to make common cause between dealing with health inequalities and dealing with the climate crisis. In 2021, in Glasgow of all places, it is the right time and place to be thinking about that. The big advantage in that context is that, if we achieve net zero greenhouse gas emissions, we will reduce air pollution and improve health as a result. It is crucial that we make common cause with dealing with the climate crisis and reducing health inequalities.

09:30  

I am assuming that, if witnesses put an R in the chat box, they want to come in. The clerks are feeding that information back to me. Does Professor Smith want to add anything?

I will be very quick. I agree with a lot of what has been said. A systemic approach to air pollution must be taken, because many of the things that impact on that are system-wide issues, such as transport, infrastructure and the location of factories. I like Professor Marmot’s really useful concept of proportionate universalism.

If we focus only on places, which sometimes happens in our efforts to address health inequalities, we lose that wider national outlook and end up zoning down on policy levers that exist at a local level, which are often insufficient. Instead of focusing on the wider issue of health inequalities at a national level, we end up focusing on small-level improvements in particular areas. It is important to make the small-level improvements that local areas offer, but it is really important that we combine that with systemic cross-cutting planning at national level. As Professor Marmot said, when we make decisions that impact on climate change, we should think about how those decisions impact on health and link together. I encourage the committee to focus on what the Scottish Government is doing to make links across different policy areas.

Sue Webber has questions on that issue.

There is a lot of synergy in what we have heard about tackling health inequalities. I am interested in what Professor Burns said about current policies focusing on a top-down approach and the need to focus on a bottom-up approach if we are to help young people when they are in difficulties and prevent their early death from suicide, violence, drugs or alcohol. We live in a world of finite resources, and we want to focus on a bottom-up approach, so what do we do about the top-down approach, because we cannot be everywhere? Right now, our resources are going towards tackling waiting lists, and hip and knee replacements are for the older generation, but you said that we need to focus on supporting the young. How do we square that with the public? How best should we do that?

Your sound broke up a wee bit, but I think that you are asking how we square what politicians in Parliament can do with the bottom-up approach. The most important thing is to give people on the front line the permission to begin to do stuff.

I will give an example. I spoke to a group of district nurses in a significantly deprived part of Scotland who told me that, when they get together in the office for cups of tea, they share stories about families and so on. They knew about 30 families who were really struggling, and they wondered how often they went to the accident and emergency department of the local hospital. They got the names together, asked the local hospital and found that members of those families were going to the local A and E department once or twice a week. One of the district nurses happened to be talking to the local community police officer, who said, “I know who those people are.” He went away to find out how often members of those families were dialling 999 and, again, it was a very high number.

I hear those kinds of stories all over the place, and what I take from them is that we need to bring together the front-line staff in the different parts of the system and ask them, “Who is struggling and how do we reach out to them?” Because it is difficult to get the data, I have never done so, but if we asked the local education department about the children in those families, I bet that we would find that the children attended school only 50 per cent of the time.

Therefore, it is a whole-system problem, and the most important thing is for Parliament to give permission to the front line to begin to reach out to those individuals and ask them, “What do you need? How can we help you? How can we support you to improve control over your lives?” From a whole range of studies that have been done, we know that control is the most important thing. Hopelessness and helplessness cause such families to struggle, so if we give them hope and a feeling that they can be in control of their lives, we will find that a lot of those issues turn around. We need to create an environment that allows individuals to be helped by front-line staff and that allows front-line staff to come up with solutions.

I have just finished a year as president of the British Medical Association. I do not get involved in the politics of the BMA, but it supports me in doing a project. As part of that project, I asked all the general practitioners in Britain to send in stories about how they helped struggling families. We are pulling those stories together and we will have a conference about the project next month. We need to pull together and share those stories of how we reach out to individuals and change their lives, so that we can begin to build a programme of support for families who are struggling.

I have a quick follow-up question. Professor Burns, you spoke about how difficult it is to get the data. In the example you gave, members of front-line staff showed a lot of initiative and did some digging around. In terms of data sharing, how important is it for us to have systems that talk to one another?

That is very important. I have struggled to get data. I have a research assistant who has been trying for a long time to pull together data to allow us to begin to identify people who need help, but I think that I am making progress with the Scottish Government on that. Under general data protection regulations, in effect, all that data rests with the Scottish Government, and we need to pull it together. Let us say that the data tells us that, in an area of Scotland, 500 people are in difficulty, so we begin to support them in different ways. If we follow that up a year later and find that that 500 has fallen to 100, we will know that we are making progress.

There are examples. A few years ago, the city of Stoke-on-Trent calculated that the public sector was spending about £100,000 a year on individuals who were struggling. Once the city implemented the provision of bottom-up support, the figure fell to about £400 or £500 a year. Those are very soft figures, but they show that the public sector can do things differently and save a lot of time and effort in the process.

The question about whether to have a top-down or a bottom-up approach is such an important question. In my research, I put a lot of emphasis on how much control individuals have at work, because being in situations without control increases the risk of physical and mental illness. Indeed, when I chaired the World Health Organization commission on social determinants of health, we privileged empowerment, which we thought of as acting not just at an individual level but at community and, indeed, national level.

In its recent—and much maligned, including by me—report, the commission on race and ethnic disparities said, “No, no, no—there’s no structural racism in Britain. We think that individuals and communities should be empowered to take control of their own lives.” That really gave me pause and made me think, “Have I got this wrong?” When I saw that a group that had said that there was no racism and that there were no structural causes of inequality had also said that it was up to individuals and communities to act for themselves, it made me think that everything that I had been saying for decades was completely wrong.

I do not think that allowing people to take control of their lives means that the state should have no role. I have written about poor parts of Glasgow based on case histories that were given to me by John Carnochan, a detective superintendent in charge of homicide. He described a typical individual growing up in Calton in Glasgow. This boy had a single mother; the family moved home every 18 months; and the mother had a succession of partners, each of whom abused this young fellow. By the time he went to school, he had already been labelled as having a behavioural problem. As soon as he was old enough, he was involved in gangs and was then labelled as a juvenile delinquent. He never had a proper job; he drank, smoked and did drugs; and he was thrown out by girlfriends because of his violent behaviour.

Are we going to come along and say to such a person, “We’re going to let you take control of your life. Pull your socks up and look after yourself. Stop drinking, eat properly, get a job and stop abusing your girlfriend”? That is a parody—a grotesque caricature. Instead, we need to create the conditions for people to take control of their lives. If that young person had had a stable background and a decent education and then chose to do whatever he did, that would be up to him. However, if we do not create the conditions that allow people to take control of their lives, we are not doing our job properly.

My response, therefore, to the question of whether we need top-down or community involvement is that we need both. Ultimately, people should be able to take control of their lives, but we need to address the social determinants of health and health equity that give them the capabilities to do so.

You wanted to come back in, Professor Burns.

I want to go back to what Professor Marmot was saying with regard to some people making good decisions while others make bad ones and some people being in control while others are not. I point to the strong body of scientific evidence that shows that children who experience chaotic early lives are less well able to make such decisions. Studies that were done in America first of all show that, in children who had experienced adversity in early life, the centres of the brain that control emotions, decision making and learning developed abnormally. We did some studies in Glasgow that showed exactly the same thing. People at the lower end of the social scale had structural abnormalities in the brain. We measured function, as well. Those individuals were more emotionally arousable. They were more anxious, aggressive and fearful, less well able to make decisions when faced with difficult choices, and less well able to learn at school. That is what happens when people have a chaotic and difficult early life.

09:45  

Regrettably, Bruce McEwen, who was the neuroscientist in New York who showed that, died last year. However, before he died, he told me that he had done a study that showed that those changes could be reversed in later life. An important part of the process of repairing and restoring from those problems is mentoring—the support of a trusted other person to help those individuals to begin to feel in control of their lives.

The system is very complex. It is right that we need top-down support to allow people on the front line to engage and help those individuals in an appropriate way. We also very much need the ability to pull together the data that demonstrates that we are making change happen.

I am going to turn my video off. That might help.

I go back to the original point about how we decide what to focus on if we have limited resources. I completely agree with what Sir Harry Burns said about having to think about systems and how the different bits of the systems interact. We can do that at the local level, as Sir Harry Burns described, and we can also do it at the national level, in respect of how we make national policy decisions. I am currently involved in a project that is trying to support the Scottish Government to do that—there will be others. The project that I am involved in is funded by the UK Prevention Research Partnership and is called SIPHER—systems science in public health and health economic research. It is trying to implement decision-support tools based on systems modelling rather than the more silo-based modelling that we have tended to have. It is looking at what happens if one thing is done—one policy decision is made—in the system and how that impacts on the other areas of the system at the national level.

We need that national level systems thinking as well as the local level systems thinking and, for that kind of modelling and systems thinking to work, we need good data, so I also agree with what Sir Harry said about that. The Covid pandemic has highlighted data around ethnicity, which is a key area that Scotland is not doing particularly well in. That is really problematic in Scotland. It would be good to ensure that more effort is put into ensuring that we have the right data. If we are not even capturing the data that we need, we cannot feed that into that kind of evidence-informed decision making and modelling.

It is, of course, really important to bring the public with you in a democracy but, for me, that does not mean doing things only at a grass-roots level. We also need to think about what mechanisms we have in Scotland for bringing the public into conversations about macro level policy decisions. How are we having those public conversations? Where are they taking place?

I have done research over many years that has looked at how policy makers and researchers have tried to tackle the issue of health inequalities. In the course of that research, many people have told me that members of the public do not support the kinds of evidence-informed policy proposals that researchers have put forward. However, when I explored that idea via a national survey in citizens juries, that did not appear to be the case. In fact, members of the public seemed to understand the social determinants of health very well—particularly, as we might expect, if they had experienced deprivation—and they were also very supportive of policy decisions that were trying to address social determinants of health, such as housing. They gave clear and persuasive accounts of how changing something such as housing has a knock-on impact on many different aspects of people’s health and wellbeing. Therefore, it is really important to think about how we have those public conversations, and we also need research to better understand what the public actually think about issues such as health inequalities and potential policy interventions.

We will now move on to questions from Emma Harper.

Thanks, convener, and good morning to our panel of experts.

The Scottish Government has published its public health priorities, with a number of items that need to be addressed. Among the priorities are:

“A Scotland where we flourish in our early years ... A Scotland where we have good mental wellbeing ... A Scotland where we reduce the use of and harm from alcohol, tobacco and other drugs”.

Six priorities are listed. This is the first time that Scotland has had a simple, overarching public health strategy, and it is the first time that the national public health priorities have been aimed at wider determinants of health.

I am now co-convener of the cross-party groups on health inequalities, on improving Scotland’s health and on diabetes. I am trying to bring them all together so that we can have everybody round the table having the same conversation, instead of having different conversations in silos.

I am interested to hear whether the expert panellists agree with the Scottish Government’s public health priorities. Do you think that something needs to be added?

From what you have just said, that is a pretty good list. In my English review, I had six domains of recommendations to reduce health inequalities. Interestingly, a Swedish commission picked up my six, which I will tell you, and it added a seventh, which I will also tell you. I think that they apply well to Scotland.

The first domain was early child development: give every child the best start in life, with equity from the start. That is exactly what Harry Burns has been talking about and what you have just said.

The second domain was education and lifelong learning.

The third was employment and working conditions. It is important that the transition from school to work and reducing the proportion of young people not in employment, education or training are in that.

The fourth recommendation was that everyone should have at least the minimum income necessary for a healthy life. That is a hot issue this very week in England, with £1,000 a year about to be taken off universal credit. It took a young footballer to get the Government to do a U-turn on free school meals for people who could not afford to feed their children. It somehow took a young footballer to shame the Government into saying that it was really not very good if poor kids went to bed hungry.

The fifth, which relates to the earlier discussion about pollution, was on healthy and sustainable places in which to live and work. That includes housing—[Inaudible.]—environments and transport, and that very much relates to the climate issue.

The sixth was about taking a social determinants approach to prevention. Harry Burns talked about drugs and alcohol; we could add smoking, diet and exercise. That is not simply about telling people to eat well or to behave properly; it is about dealing with the social conditions relating to behaviours.

The seventh domain, which the Swedes added in their commission, was people having control over their lives. That, of course, underpins the others.

Those would be my priorities. If you ask me what I would recommend for Scotland, I would recommend those same priorities.

I am very supportive of Scotland’s public health priorities. They are a great list of priority areas. Tackling inequalities in wealth and poverty is not as clearly highlighted in the list as it could and should be for Scotland but, beyond that, it is a really good set of goals that Scotland is aiming for.

The issue is how we achieve those goals—how we create the policy decisions that will achieve those policy priorities and goals and make them realistic. That is where we need the systems thinking. It is a wide-ranging list that cuts across a huge range of policy areas, so you need policy tools that will help you to think about where you will get the win-wins and the best returns on your investment in that system. That is a key point.

The other issue is how policy making in the Scottish Government interacts with the wider political system. It is great to see the Scottish Government trying to join up its policy making on public health—I know that the public health reforms have all been centred on that. However, when policy making interacts with that wider political system, the lobbying and advocacy that goes on, with different organisations, for very good reasons, trying to influence policy, can pull things back to silo-based policy making. We need to think about how Scotland can maintain that focus on joining things up and not get pulled into focusing on one specific issue because there is lots of advocacy and lobbying and lots of media attention on that issue.

As Sir Harry Burns said, it can be politically very attractive to feel that you are fixing one very clear thing and that you can see what you are doing on that issue. We need to get on board with the public health reform agenda but maintain that cross-cutting approach and really go with that systems thinking and thinking about where you can get your best buys.

[Inaudible.]—both Michael Marmot and Kat Smith on what they have been saying. We have to get in behind it, but the question is: how do we do that? How do we deliver it? In fact, Scotland has a good track record on that. When we did the patient safety collaborative about 10 years ago now, we reduced surgical mortality and standardised mortality rates in hospitals significantly. Internationally, the way that we did that was held up as world leading. We did it by asking front-line staff to come up with ideas.

I can tell you a story about the early years collaborative. It was decided that one of the things that we needed to do was to ensure that 90 per cent of all children reached all their developmental milestones by the 30-month health visitor assessment. When we started doing that, we discovered, to our horror, that only 60 per cent of Scottish children actually got a 30-month health visitor assessment.

All sorts of heads were being scratched, but one health visitor in one clinic in one health board authority wondered whether parents were not turning up because the appointments were sent out in brown envelopes—brown envelopes are not very popular in houses in deprived areas. She started to text the times of the appointments to families and, before we knew it, 90 per cent of all children were being brought for their assessment. She told all the other nurses in that clinic, who told all the other nurses in that health board and, eventually, across Scotland, 90 per cent of all children were being brought to their assessments. That shows you how one front-line staff member can have a clever idea and a clever insight and that, if we spread the learning, we get significant change and improvement.

Before we started the early years collaborative, Scotland had the highest mortality rate of the four UK countries; now we have the lowest infant mortality rate of the four UK countries. Big change can take place. Sitting in Holyrood and in academic departments and so on, we can say, “This is how we might do it,” but actually doing it requires the involvement of front-line staff to help to shape and deliver it. Yes, let us go full pelt with that list of priorities, but let us create a collaborative approach to make it happen.

I am thinking about low-hanging fruit. Healthcare providers are starting to get more education about adverse childhood experiences. Police officers in South Ayrshire are now going through training to recognise ACEs, which is really important. When I started my vaccination programme training, there was nothing in the e-learning modules about tackling stigma related to alcohol and drugs for healthcare professionals who work outside alcohol and drug services. If we are thinking about low-hanging fruit and on-the-ground delivery of education, do you think that we need to consider ensuring that healthcare professionals know about adverse childhood experiences as well as things such as the stigma that is related to alcohol and drugs?

10:00  

You are absolutely right. We need to be aware of those issues. I have been working with Police Scotland and councils in Ayrshire and elsewhere to get them to realise that. Some people are taking that point on board very well.

Systematic training around adverse childhood experiences is important. A lot of our learning on adverse childhood experiences comes from a big study that was carried out in California many years ago that showed clearly the link between the number of adverse childhood experiences and the extent of poor health and wellbeing outcomes.

The interesting thing about the adverse childhood experiences clinic is that it started off life as a weight reduction clinic. The clinicians wanted to reduce people’s weight, but they found that they could not do so with lots of folk. By chance, one of them discovered that the patients whom he was dealing with had suffered abuse and neglect as children, so it was changed to an adverse childhood experiences clinic. That shows you just how complex a problem such as obesity is. When I hear ministers say that they want to ban the advertising of high-calorie foods on television, I think, “Aye, that’ll be right; you’ll get a good result out of that.” The issue is much more complex than that—that is the basic problem.

You are right. Awareness of adverse childhood experiences is important, as is collecting the data, identifying the people who need help and support, and not stigmatising them. They are as they are because of the situations that they were in. Helping them to take more control of their lives is the way ahead.

A couple of members want to ask questions about policy priorities. However, before that, I believe that Professor Marmot would like to comment on the issue that we are currently discussing.

I have been to three meetings in Edinburgh about early childhood. The third one was specifically about adverse childhood experiences, and I was very impressed by the level of focus on that issue in Scotland. During the coffee break, a group of public health students from the University of Edinburgh were buzzing around me and filling my ear with the view that it is all very well for practitioners to be concerned with adverse childhood experiences but that it is also important to consider the social and economic drivers of those experiences. That is exactly what Katherine Smith said earlier. We cannot just get practitioners to focus on adverse childhood experiences and ignore the social and economic inequality that gives rise to those experiences. We know that adverse childhood experiences follow the social gradient. If you look at nine specific adverse childhood experiences, you will see that they all increase in frequency with deprivation—the greater the deprivation, the greater the frequency of ACEs.

It is great that practitioners are aware of the issue and are focusing on it, but the issue in general absolutely emphasises Katherine Smith’s point about the importance of putting ACEs in the context of addressing social and economic inequalities.

You have already answered a lot of my questions. Adverse childhood experiences are often on the edges of lots of other things that we talk about. I feel that the film “Resilience” should be shown everywhere or, at least, to everyone in the public sector so that people really understand how toxic stress changes the brain and how it can impact on people in later life as well as affect their health and wellbeing all the way through.

Is there a case for having a specific focus on ACEs? Should we be working with young people on the issue, talking to them about it in schools and asking them to consider whether they have any ACEs in their own backgrounds? I know that a lot of people who work in public health and social work have suffered quite a lot of ACEs in their lives themselves, so despite all the negative impacts, there are also some positives to consider.

This is not about just writing down a list of things that might have happened to a person and then saying to them, “You’re going to have problems in your life because of these things.” Instead, we need to sit down and look at and understand the issues. This is about being in control and having a sense of wellbeing as well as about understanding and appreciation.

Were you directing those comments to anyone in particular or should I just go round everyone?

It is fine to ask for general comments.

I will ask Professor Marmot to respond first and then bring in our other panellists.

Forgive me for going far afield, but when I visited Australia I was interested to see that, with regard to the health of indigenous Australians, the default position of the care services was not whether but when to take a child into care because of adverse childhood experiences. The default was that Aboriginal parents were incompetent; drug and alcohol abuse and domestic violence were involved; and the children needed to be taken into care.

However, pretty well almost everybody to whom one speaks agrees that taking an Aboriginal child into care has disastrous consequences, and it costs about $100,000 a year. My question was: for $100,000 a year, could people not work with the families to do something about the problems of drugs, alcohol and domestic violence? In Victoria, there is a group of healthcare organisations that are controlled in the community by indigenous Australians. In one rural district, they told me, “We’re doing this. We’ve taken formal responsibility and we use the money to work with families on the problems of drugs, alcohol and domestic violence.” Their default position is to keep the families together and deal with the problems.

I never make the economic case for doing the right thing—I think that we should do the right thing because it is the right thing to do—but these people are making the economic case, too, that dealing with the source of these problems in adverse childhood experiences is quite cost efficient. Given the problems that come down the line if you do not deal with it, it is worth spending the money up front.

As I said in response to the question about whether there should be top-down or community control, we need both. We need to deal with the structural drivers, but we must also have community and professional engagement in order to deal with the problems of ACEs where they occur in families and communities.

I am reluctant to label families and say that the problem is all due to ACEs. Part of the problem is that we have tended to focus on and tried to do something about a particular thing, and there is a great risk in doing so.

There are families in which the parents are very loving and keen to do the best for their children but just do not have any money or resource to fall back on. The issue is about providing support for families, but not because they are so-called bad families. Telling people who are struggling that they are bad and that their children might have to be taken away will just make them feel even more hopeless. That is a classic example of when we need people on the front line to go in. My conversations with Police Scotland officers have shown them to be really understanding about that. They see the consequences of chaotic families. The policemen whom I have spoken to say, “We don’t want to disrupt those families; we want to help them.” We need Parliament to send a positive message that building trusting relationships with struggling families works.

A couple of years ago, I was at the national rural health conference in Australia, and exactly what Michael Marmot talked about was happening. There was a really interesting presentation from two guys who spoke to homeless folk. One of the things that homeless people were anxious about was the fact that their clothes were dirty, so those guys got a van, put a washing machine and a tumble dryer in it, drove around the city to places where they knew homeless folk congregated and washed their clothes for them. Solutions emerge in unexpected ways. That system has now spread to many Australian cities.

If we ask people what they need and help them to achieve that, they begin to take control of their lives. Although I talk a lot about ACEs, I do not want people to be labelled in such a way or there to be a national ACEs programme; I want a “let’s help people who are struggling” programme.

I very much agree on the importance of focusing on early years, on which the research literature is very strong and goes back decades to the Black report and beyond. It is clear that, if we want to tackle health inequalities and inequalities generally at a societal level, we need to think about early years.

For many of the reasons that Sir Harry Burns has given, I share his concerns about a focus on ACEs and explicitly labelling them as such. First, lots of different issues are merged under that label, and they sometimes need to be unpicked a bit. Secondly, it becomes a label in itself, which is exactly what Sir Harry Burns warned about, and that label could be quite stigmatising. Thirdly, a recent review of the literature on ACEs by David Walsh from the Glasgow Centre for Population Health and his colleagues found that only a tiny proportion of the literature explores the socioeconomic context of ACEs. If we do not make those links, we miss a huge amount of the picture. If we focus on ACEs, it is important that there is a wider conversation and that the label does not become a stigmatising tool that makes conversations difficult and people unwilling to engage.

My questions are on Covid-19 and its wide-ranging impacts. Every day, we see the direct impacts of the disease in terms of the number of hospitalisations and deaths, but I am interested in the longer-term indirect effects on health and in the impact that long Covid might have, particularly on people who already suffer from poor health or live in areas of deprivation.

If we take long Covid first, I am keen to understand its impact. We obviously do not have a lot of data and information on it yet. That is emerging, and there is still a long way to go in terms of interventions, but I am looking to get a sense from the panel of the impact that long Covid will have and what interventions it might require.

10:15  

I could say more about the impact that Covid has had on how we think about health inequalities and public health than about long Covid specifically, precisely because, as you said in your question, the data on long Covid and our understanding of it are limited at the moment. There appears to be a gender and an age group dimension to it, but evidence in that area is rapidly evolving. It is probably too soon to make a call about what the impact of long Covid will be, but it seems that it will be unequal, as we would expect and as the more general impact of Covid has been.

Generally, the way that the Covid pandemic has played out is as what my colleague Clare Bambra calls a syndemic, in that it has interacted with existing health and societal inequalities. Those inequalities have worsened the impact of Covid and made it more unequal, and the impact of Covid is making the inequalities worse. It impacts directly in terms of who has been most at risk of getting sick in the first place and who is most at risk of serious complications and illness if they get sick. The wider implications of its impact on people’s ability to work, care for their families and so on, have also been unequal, which is unfortunately exactly what people working on health inequalities would have predicted at the start.

In the context of health inequalities, Covid has drawn attention to an issue that has been on the agenda for a long time but has not had enough of a policy focus to reduce the inequalities in the way that we would like to. Many of the factors that explain why the impact of Covid-19 was so unequal are precisely the same social determinant factors that we have talked about for so long in the context of health inequalities. Certain people are more vulnerable because they already have a higher burden of other illnesses, their immune systems are not as effective, and they are more exposed to it. They are more likely to have had to go to work and to be living in cramped housing conditions, and they have less access to nice outdoor space, so there is increased transmission.

All those reasons explain the unequal impact of the pandemic and we would expect to see that in the impact of long Covid. What can we do about that now? I would be wary of trying to be too ameliorative. It really behoves us to think about the more upstream social determinants approaches that have been on the agenda for so long but that we have not quite managed to nail in Scotland in the way that I think we have the potential to.

[Inaudible.]—locus of control if you feel pushed around by circumstances outside you and are not able to overcome them. If you feel rubbish all the time, if you are tired, have chronic headaches and so on, that just worsens your sense of control. For people at the lower end of the social scale who have a poor sense of control, it will just make life worse in a way that is very difficult to detect. There is no test to show that people have become more depressed, isolated and so on, because the combination of inequality, poverty and Covid has made a difference.

One of the most striking things has been the differential death rates in affluent and deprived individuals. I will speculate on one of the reasons for that and I would love to hear what Professor Marmot thinks about it. There will be a reason in as much as people at the lower end of the social scale will already have a number of conditions that will make recovery difficult for them.

Many years ago, Professor Marmot described the fact that people at the lower end of the social scale have higher stress hormone levels than people at the higher end. One of the things that has been speculated in relation to Covid concerns the idea of a cytokine storm—a rush of stress responses that damage the body. That might well explain some of the difference.

Covid has worsened inequality and will continue to cause problems for people at the lower end of the social scale if they have continuing effects of having had the virus.

I agree completely with what Katherine Smith and Harry Burns have said so eloquently. Covid and the response to it, in the form of the lockdown, have amplified the underlying inequalities in society. Because we have controlled the pandemic so poorly, inequality has increased.

Let us take a step back and think about excess mortality in the first phase of the pandemic, in the first half of 2020—that is, the difference between the expected level of mortality, based on the previous five years, and the level of mortality that actually occurred. We know that the excess mortality was higher in England than in Scotland and that it was higher in Scotland than in Wales and Northern Ireland. We also know that the excess mortality in the UK as a whole was higher than it was in any other rich country. We look at the US and say that its handling of the pandemic in 2020 was a disaster, but we were worse: we had higher excess mortality than it did. The excess mortality in the US is now higher than it is in the UK, but we are right up there.

When I looked at the Johns Hopkins University figures yesterday, I saw that we are at about 45 new cases per 100,000 people daily, and the US is at about the same. However, our rate is about four times higher than the rates in Germany, France and Italy. We have managed the pandemic appallingly badly.

I saw recently that, from 2010 to 2019, the UK showed the slowest improvement in life expectancy of any rich country apart from the United States and Iceland, although it was only the US that really did worse than us. If you look at the excess mortality during the pandemic and the improvement in healthy life expectancy in the decade before the pandemic, you can see that the worse the improvement in health before the pandemic, the higher the excess mortality during the pandemic.

I have asked myself what the link is. Why do countries that have a poor health record before the pandemic have a poor record of managing the pandemic? I think that the link potentially works at four levels. The first is the quality of governance and political culture. We really managed the pandemic badly. You know, when freedom day was declared in July, we had 45,000 new cases that day. In Australia, when they had 1,000 cases, they had a complete lockdown, but 45,000 cases was a fine level for us to declare freedom.

The second level is the increasing social and economic inequalities—the kinds of things that Katherine Smith was referring to. The third is the disinvestment in public services during the previous decade. The fourth was that we were not very healthy coming into the pandemic, and that increases risk.

Standing back, it is plain to see that the pandemic increased inequalities, and part of the reason for that is that we managed it so badly. For example, we asked people to isolate but did not give them the economic resources that made it possible for them to do so. A study from Liverpool showed that one reason why poorer people were not coming forward for Covid testing was that they were scared that, if they tested positive, they would have to stop work, and then they would starve. We did not make the proper economic arrangements to help us control the pandemic.

That is quite apart from the point of Harry Burns’s speculation—which I agree with—that being lower in the social hierarchy puts you at higher risk of a whole range of disorders because of stress responses.

Good morning. With the pandemic causing huge backlogs for the national health service, as well as pressure on it from politicians and the media especially, do you think that primary prevention will be neglected?

I am sorry, I am not quite clear what you are asking. Is it about primary prevention of other conditions?

Yes.

I have no insight into that. If you are talking about the increased workload of the health service, it is clear that things such as follow-ups to screening tests have, in some places, been put on hold, and we are seeing the consequences of that.

I have been thinking that there should be an audit. We should look very closely at what tests and interventions have been delayed, because there is a chance that things will get worse as we move into winter. I get the sense that the NHS is trying very hard to recover but, if things get worse over the winter—as we might expect them to do—we might be back to square 1.

Therefore, we need to try to understand where and why the delays are happening now. This week there has been a lot of discussion about a shortage of ambulance crews. Are there specific bottlenecks in the process of moving people through the system that we should be tackling? We are only going to know that if we collect data. I am not sure whether that is being audited. If not, it should be, and plans should be laid to cope with a worsening situation as we move into winter. I hope that that does not happen. I hope that the third-immunisation approach to the over-55s will help with that, but things always gets worse with flu in winter. We need to start preparing for it now.

I am very conscious of time. I am going to bring in Gillian Mackay and then Sandesh Gulhane, and then we will have to wrap up.

We have talked about people‘s incomes, particularly during the pandemic. Furlough is due to come to an end, universal credit is being cut and incomes generally are declining for those who are least able to afford it during the pandemic. Would the panel agree that a universal basic income approach could help to tackle some of the economic inequalities that lead to poor health?

I would have liked to have brought in Professor Marmot at this point because he brought up that point but he has had to leave. I ask Professor Burns to answer and then Professor Smith.

10:30  

I am a fan of universal basic income. The evidence that we gather from studies in the US and Canada shows that it works. It significantly improves health and wellbeing.

I was told that, on the basis of its studies, America was prepared to make universal basic income a civil right but it was suggested that it led to an increase in the divorce rate at the time that it was being tried. Folk said that that is what happens when we make women financially independent of their husbands—they divorce them. In fact, that was a complete fabrication. The divorce rate did not go up but infant mortality fell and engagement with schools increased, for example. There are a number of very significant benefits from UBI and I am a supporter. I do not understand why the trials that were proposed never came to anything.

I agree with Harry Burns. All I would add is that there are many different designs for universal basic income. We can set it at different rates, which has big implications for how it functions in relation to inequalities. However, I agree that it is a shame that the proposed approach for trialling it in Scotland does not seem to be progressing. It would be good to see that being reconsidered.

We are coming up against the deadline for this panel of witnesses because we have a second panel, but I will bring in Dr Gulhane.

Countries with the best-working primary care seem to have better outcomes on health inequality. With GPs being completely overwhelmed, will health inequalities increase and general health decline?

Unfortunately, health inequalities will get worse in the context of the pandemic because of how the pandemic and health and societal inequalities have interacted.

GPs being overwhelmed is a real concern but, if we think about the longer-term impact of the pandemic, there are opportunities for how people think about their health and wellbeing and how they interact with the health service. Public health is much more in public and media conversations than it was previously, which provides an opportunity to facilitate better conversations and interactions. We could try to build on that wider public and media awareness of public health and the importance of interacting with health services. It would be good for Scotland to do that.

[Inaudible.]—and giving them less time to unburden themselves. I have said several times that the most important thing for someone who is struggling is the sense that they have someone who listens to them, whom they trust and whose time they value. If GPs are not able to give people time because they are overwhelmed, that will cause individual problems. There is no doubt about that.

The best GPs that I know and speak to regularly are still trying hard to give a listening ear to the people who they know are struggling. It comes down to individuals who are going out of their way to do the right thing for their patients. In Scotland, we have a high quality of primary care available to the population in general.

Sadly, we will have to allow the witnesses to go. There is so much in what they have said. I thank Professor Burns, Professor Marmot and Professor Smith for their time.

We will take a very short break—I emphasise “very short”—before our next panel of witnesses.

10:34 Meeting suspended.  

10:40 On resuming—