Health in Scotland 2009 Time for Change: Annual Report of the Chief Medical Officer

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CHAPTER 1 Trends in life expectancy and the continuing widening of health inequalities

Figure 1 updates the trends identified in last year's report. There is a continued slight narrowing in the gap between men and women in terms of life expectancy but, overall the trend is disappointingly stable.

Figure 1: life expectancy and healthy life expectancy at birth, 1980 to 2008

Figure 1: life expectancy and healthy life expectancy at birth, 1980 to 2008

Figure 2 is a statistical projection of the rate of growth in LE in Scotland for the next 2 decades. It is likely that this average rate of growth will continue to mask a widening difference in wellbeing with residents of the more affluent areas pulling away inexorably from their poorer neighbours. At present, Scotland has the lowest life expectancy of all Western European countries. We sit between the countries of West and East Europe (Figure 3). There is, however, evidence that some areas of Eastern Europe are achieving the kind of step change in health that seems likely to allow them to overtake Scotland in the coming years.

Figure 2: expectation of life at birth, Scotland, 1981-2033

Figure 2: expectation of life at birth, Scotland, 1981-2033

There have been numerous initiatives over the past decades which have had positive effects on health in Scotland and there have been significant reductions in mortality from many of the most significant causes of death. The Scottish Public Health Observatory monitors these trends. In a report comparing Scotland with other countries in Europe, the Scottish Public Health Observatory concluded that, over the last 50 years, mortality from all causes has fallen in Scotland in line with trends across the rest of Western Europe (Scot PHO 2009). However, while mortality rates for Scottish children are close to the Western European average, mortality among working age Scots, both men and women, is the highest in Western Europe and has been since the late 1970s (Leon et al 2003). Scotland's poor health is at its most obvious amongst working age men and women.

Trends in mortality amongst working age adults (15-74 years) varied considerably when different causes of death were considered. For example, Scotland now has the highest rates of oesophageal cancer in Western Europe for both men and women. However, while, lung cancer mortality rates for men and women remain among the highest in Western Europe, the male rate has reduced considerably since the mid 1970s and is gradually moving closer to the average for Western Europe. This encouraging trend is, in large part, a reflection of the success of Scotland's efforts to reduce smoking rates. Rates of colorectal cancer mortality (for men and women) and breast cancer mortality, although still relatively high, have been falling and appear to be converging towards the Western European mean. Rates of stomach cancer and pancreatic cancer mortality are close to Western European average.

Figure 3: life expectancy at birth, 2007, selected countries, males

Figure 3: life expectancy at birth, 2007, selected countries, males

There have been significant reductions in mortality from ischemic heart disease and cerebrovascular disease for both men and women over the last half-century. Despite this, mortality rates in Scotland from both causes remain among the highest in Western Europe. However, there are signs that the gap between Scottish mortality rates and the Western European average is narrowing. Again, these encouraging trends reflect, in part, the success of smoking cessation programmes as well as significant improvements in treatment offered by the NHS. Mortality rates from chronic obstructive pulmonary diseases such as chronic bronchitis are among the highest in Western Europe, although mortality for males has fallen considerably since the 1960s.

Most worryingly, Scottish mortality rates from chronic liver diseases such as those caused by excess alcohol consumption have risen steeply since the early 1990s among men and women. Rates of mortality from liver disease for Scottish men and women are now the highest (or close to the highest) in Western Europe. The need for action to reduce alcohol consumption is pressing.

Suicide mortality among adult men in Scotland has risen since 1975 and the male mortality rate for suicide is now twice the level it was in 1955. One encouraging observation is the fact that, mortality from road accidents in Scotland has declined since the mid-1970s and Scottish death rates are now lower than in the majority of Western European countries. (Scottish mortality in a European context 1950-2000 An analysis of comparative mortality trends. http://www.scotpho.org.uk)

There are, therefore, encouraging trends in the reducing incidence of premature deaths from a number of causes. Many of the conditions that are falling in incidence have been the subject of considerable effort on behalf of successive governments and the public health community within the NHS and local government over many years. This observation suggests that organised efforts to improve health in Scotland have had a significant impact. However, there is evidence that other regions of Europe have made a more rapid change - a step change - in health status. The rate of improvement in these regions, which seem to be similar in their socio-economic conditions to deprived areas of Scotland, has increased dramatically. Unless Scotland learns from these regions, it seems likely that we will miss an opportunity to make our own step change in health.

Step changes in health status

Figure 4 is a comparison of trends in life expectancy in 20 regions in the UK and mainland Europe which have suffered similar levels of deindustrialisation in the latter half of the 20th century. Walsh and his colleagues from the Glasgow Centre for Population Health have shown that in some regions of Europe life expectancy is improving rapidly in some regions (Walsh et al 2008). As Figure 4 shows, life expectancy has been improving much faster in the Polish region of Katowice than in Scotland. The 4 year gap between Katowice's and the West of Scotland's male life expectancy that was seen in the mid-1980s had been halved by 2003/05. If current trends continue, male life expectancy in Katowice will overtake that of the West of Scotland in the near future. Indeed, among females this has already happened: Figure 5 shows that life expectancy among female residents of Katowice is now greater than those living in the West of Scotland, whereas in the 1980s it was two years lower. Similar accelerations in health status have been observed in other Eastern European regions following the emergence of democracy in these countries. There appears to be a resilience in these populations which has allowed them to benefit in health terms from changed socio-political circumstances.

Figure 4: estimates of male life expectancy at birth: Katowice compared to Scotland, West of Scotland and GGC, 1982-2005 (3-year averages)

Figure 4: estimates of male life expectancy at birth: Katowice compared to Scotland, West of Scotland and GGC, 1982-2005 (3-year averages)

Figure 5: estimates of female life expectancy at birth: Katowice compared to Scotland, West of Scotland and GGC, 1982-2005 (3-year averages)

Figure 5: estimates of female life expectancy at birth: Katowice compared to Scotland, West of Scotland and GGC, 1982-2005 (3-year averages)

Achieving a step change

Albert Einstein is said to have defined insanity as "Doing the same thing over and over again and expecting different results". Herculean efforts to improve health and expenditure of significant resources has, over the past decades produced steady improvements in health which has been undermined by our failure to accelerate the health status of those at the lower end of the socio-economic spectrum. If we are to produce such an acceleration, perhaps we need to consider the methods we have been using to improve health. Perhaps it is time for a change.

In last year's report, I discussed the concept of salutogenesis, the art and science of creating health. I argued that, by concentrating too strongly on the treatment of disease, we might be missing an opportunity to build health more effectively. There has been a growing international interest in the past year in salutogenesis and its potential implications for health improvement. A number of regions in Europe are now exploring the possible policies which might support effective creation of health and reorientate thinking away from a focus on disease prevention. The scientific basis for this approach is robust and Scotland may well benefit from a closer look at the concept.

What is salutogenesis?

Basically, salutogenesis is a term first used by the American sociologist Aaron Antonovsky (1979). After a lifetime of study in many different cultures, he suggested that individuals, throughout life, develop a set of resources which allow them to make sense of the stresses they encounter in daily life so that, as he put it himself, "The stimuli bombarding one from the inner and outer environments were perceived as information rather than as noise". He termed the ability to make sense of and understand the external world as a "sense of coherence". He defined it as the quality which:

"... expresses the extent to which one has a feeling of confidence that the stimuli deriving from one's internal and external environments in the course of living are structured, predictable and explicable, that one has the internal resources to meet the demands posed by these stimuli and, finally, that these demands are seen as challenges, worthy of investment and engagement."

In essence, a person with a well developed SOC when confronted by everyday stresses will:

  • be motivated to cope (find life meaningful);
  • believe that he has the capacity to understand the challenges of everyday life (find life comprehensible);
  • believe that resources to cope are available (find life manageable).

Failure to manage a difficult environment effectively, Antonovsky argues, will cause the individual to be chronically stressed and, over a long period, impair his or her physical and mental health.

Scientific evidence for chronically raised stress associated with deprived socio-economic circumstances is now robust. Antonovsky's concept of creating health through supporting individuals to understand their social environment and to take control of it seems an important mechanism for reducing stress. It may be that an important element of attempts to improve Scotland's health should involve developing methods to increase resilience in our young people and supporting adults who lack the incentives to engage with their social environment to do so. Perhaps the time has come to debate whether our approach to health improvement might produce the necessary step change in health creation which Scotland needs to accelerate gains in healthy life expectancy.

What would a salutogenic approach to health look like?

Morgan and Ziglio (2007) have pointed out that approaches to the promotion of population health have been based on a deficit model. That is, they tend to focus on identifying the problems and needs of populations. The organisational response to these problems is to provide professional resources and interventions which produce high levels of dependence on hospital and welfare services. We do things to people rather than doing things with them. We reinforce their dependency and encourage passivity in the face of problems.

These deficit models are important and necessary to identify levels of needs and priorities. But they need to be complemented by some other approaches as they have many adverse consequences. Deficit models tend to define communities and individuals in negative terms, disregarding what is positive. Deficit approaches miss opportunities to allow individuals and communities to react positively to the problems they encounter. Instead of taking control, they are encouraged to remain passive as others try to do things for them.

In contrast, asset models tend to accentuate positive capability within individuals and support them to identify problems and activate their own solutions to problems which they themselves identify. They focus on promoting health generating resources that promote the self esteem and coping abilities of individuals and communities, eventually leading to less dependency on professional services. In effect, by concentrating on the strengths of individuals and communities, their sense of control over their lives is enhanced and they experience less of the chronic stress which leads to a range of health consequences.

Much of the evidence available to policy makers to inform decisions about the most effective approaches to promoting health and to tackling health inequities is based on a deficit model and this has, inevitably, produced policies and practices which disempower the populations and communities which are supposed to benefit from them. An assets approach to health and development embraces a positive notion of health creation and in doing so encourages the full participation of local communities in the health development process.

Morgan, Davies and Ziglio (2010) have developed this argument into one which may offer a more resourceful approach to tackling health inequities. They suggest that by developing the stock of key assets necessary for promoting health within individuals it should be possible to restore the balance between the assets and deficit models for improving health of individuals and communities. By developing assets which support health in individuals rather than by doing things to them, thereby undermining a sense of control and self esteem, it becomes more likely that a positive attitude to health and wellbeing would be created. Failing to develop the assets which allow individuals to be resilient in the face of the various circumstances which damage their health may well be the factor which has limited the effectiveness of many well intentioned health improvement programmes in Scotland during the past decades.

The late Jimmy Reid described the problem with great perception and eloquence in the speech he gave when installed as Rector of Glasgow University in 1971:

"Alienation is the precise and correctly applied word for describing the major social problem in Britain today. People feel alienated by society. In some intellectual circles it is treated almost as a new phenomenon. It has, however, been with us for years. What I believe is true is that today it is more widespread, more pervasive than ever before. Let me right at the outset define what I mean by alienation. It is the cry of men who feel themselves the victims of blind economic forces beyond their control. It's the frustration of ordinary people excluded from the processes of decision making; the feeling of despair and hopelessness that pervades people who feel with justification that they have no real say in shaping or determining their own destinies.

Many may not have rationalised it, may not even understand, may not be able to articulate it. But they feel it. It therefore conditions and colours their social attitudes. Alienation expresses itself in different ways by different people. It is to be found in what our courts often describe as the criminal anti-social behaviour of a section of the community. It is expressed by those young people who want to opt out of society, by drop outs, the so-called maladjusted, those who seek to escape permanently from the reality of society through intoxicants and narcotics. Of course it would be wrong to say it was the sole reason for these things. But it is a much greater factor in all of them than is generally recognised."

Inadvertently, in seeking to improve the lot of the most disadvantaged members of our society, we may have made them more, rather than less alienated by doing things to them rather than with them.

Asset based health improvement in action

There are many examples of interventions which have been successful in improving wellbeing but which have, usually inadvertently, done so through developing assets rather that filling perceived deficits. One well known example comes from South West England.

Beacon and Old Hill

When one thinks of Cornwall, one usually has a mental image of beautiful countryside, thatched cottages and afternoon teas. Yet, in the mid 1990s, Cornwall housed one of the most deprived council estates in Britain. Penwerris, the electoral ward comprising the Beacon and Old Hill estates which had a population of 6000, had, according to a University of Bristol report, the largest percentage in Cornwall of children in households with no wage earners, the second highest number of children living with lone parents. Unemployment rates on the estates were 30% above the national average, child protection registrations were high, postnatal depression afflicted a significant number of mothers, domestic violence was common and violent crime, drug dealing and intimidation were commonplace.

By 1985, quality of life in the area was plummeting. "It had the reputation of being a 'no go area' for the police, crime and vandalism were spiralling out of control, and the community had become more or less completely dissociated from the statutory agencies." (Durie et al)

Two local health visitors, Hazel Stuteley and Philip Trenoweth are credited with beginning the regeneration of the area after a particularly disturbing series of events. In the Health Visitors' own words:

"The flashpoint came simultaneously for us both, literally in Rebecca's case, when she witnessed the family car ignite following the planting of an incendiary device. She was
11 years old then and although physically unhurt, she was deeply traumatised by this. Already in mourning for her friends' pet rabbit and tortoise, which had recently been butchered by thugs from the estate, this was the final straw.

As family Health Visitor for the past 5 years, I was a regular visitor to her home. Her Mum was a frequent victim of domestic violence and severely post-natally depressed. My caseload had many similar families with multiple health and social problems. Seeing Rebecca and her family's deep distress, I vowed then and there that change must happen if this community was to survive. I had been watching it spiral out of control for long enough."

Thereafter, the two health visitors embarked on a series of meetings in which they tried to engage statutory agencies with members of the community. Of note was the fact that many individuals they thought would want to be involved in turning the area around refused to become involved and many of the public meetings held to encourage dialogue were described as 'stormy'. What is apparent from the descriptions of the process is that the people were listened to. The residents identified the problems they were most concerned about and statutory agencies engaged with the community in designing a response. Residents became co producers of solutions rather that passive recipients of actions others had determined would be good for them.

This was, in my view, a critical part of the process. People learned that expressing their concerns was not a waste of time. They learned their opinions had value and that they mattered to others. Social networks developed and problems became shared. Importantly, solutions emerged from these interactions between people who had previously been alienated from each other.

"The most significant aspect of the regeneration process on the Beacon and Old Hill estate was that, from the outset, there was no initial funding, no hierarchy, no targets, no business plan, only a shared vision of what the community wanted to be, rather than an obsession with what it had to do. Thus, the regeneration process was not a result of a predetermined plan. Rather, the process emerged as a consequence of the interactions between the members of the community, and between the community and its environment, namely the statutory agencies, the police, the council, and so forth. As the community evolved, so also the agencies and professional bodies co-evolved with the community." (Durie et al)

The story of Beacon and Old Hill is one of a few individuals being motivated by the failure of conventional approaches to a problem to try something different. In listening rather than lecturing, they heard the members of the community outline solutions to their difficulties. Finally, they were confident enough to allow solutions to emerge organically rather than through a conventional project planning approach which relies on the outcome being predetermined. In effect, leadership in this case did not involve taking a community in a predetermined direction, but rather involved helping individuals discover their own direction by awakening within themselves the capacity to take control of their lives. They had used an asset model rather than focussing on the deficiencies in the lives of the community.

The asset model is not new. In 1986, the World Health Organization held the First International Conference on Health Promotion in Ottawa. The conference culminated in the presentation of a Charter which identified action necessary to achieve health for all by the year 2000. Among the elements of the Charter, it includes the following statements:

"Health promotion is the process of enabling people to increase control over, and to improve their health. To reach a state of complete physical, mental and social well-being, an individual or group must be able to identify and to realize aspirations, to satisfy needs, and to change or cope with the environment. Health is, therefore, seen as a resource for everyday life, not the objective of living. Health is a positive concept emphasizing social and personal resources, as well as physical capacities. Therefore, health promotion is not just the responsibility of the health sector, but goes beyond healthy life-styles to well-being.

Health is created and lived by people within the settings of their everyday life; where they learn, work, play and love. Health is created by caring for oneself and others, by being able to take decisions and have control over one's life circumstances, and by ensuring that the society one lives in creates conditions that allow the attainment of health by all its members. Caring, holism and ecology are essential issues in developing strategies for health promotion. Therefore, those involved should take as a guiding principle that, in each phase of planning, implementation and evaluation of health promotion activities, women and men should become equal partners.

The founding principles of health promotion have included the ideas of enhancing control over life circumstances and ensuring that citizens are equal partners in creating better lives from themselves. These principles are in use in many programmes across Scotland. But, often, they are most evident in small projects and it is not explicitly recognised that the project is developing assets in the community rather than trying to fill deficits. Among the many programmes and activities which seem to focus on developing assets is the work carried out in Scotland's Healthy Living Centres.

Healthy Living Centres

Healthy Living Centres ( HLCs) aim to be at the heart of their communities. Around 200 development staff and over 1200 volunteers in 26 HLCs engage with over 130,000 local people every year. Around 250 local people are actively engaged in the management and operation of HLCs through their voluntary participation as Board members. For every £1 of Government and local authority support, HLCs have estimated that they bring a further £3 into their communities. HLCs try to make a difference because they take time, build trust and network, inspire ambition, give hope and help individuals to feel good about themselves, their families, neighbours and communities and do well as a result. Being positive and optimistic, sometimes in the face of major difficulties and challenges is how HLCs work with their communities. Being responsive, flexible, innovative and on occasion radical is how HLCs support individuals and communities to build resilience and confidence in themselves and in the future. This is particularly evident in the ways in which communities use their resources to invest in the health and wellbeing of their youngest members and their families.

These examples from HLCs reflect the variety of ways in which they work:

Camglen Community Radio Nursery Shows involve 3 and 4 year olds in producing radio shows which are broadcast live on local radio organised by the HLC. This activity demonstrates the willingness of local organisations and families to be involved in community activity. The ability and enthusiasm of very young children to learn skills which are normally associated with adults is obvious. Moreover, it is local adult volunteers who are involved in Camglen Radio who pass on and teach those skills. Also demonstrated in this example are the benefits of having the appropriate and community-managed resource of a well-equipped radio studio, which encourages so many sections of the community to engage with the project. This activity is in its third year.

A One-Stop Shop for Parents is organised weekly in community venues. It builds on the connections between various local agencies who 'set out their stall' in an informal setting which encourages parents to generate their own ideas and sparks interest in other aspects of healthier living.

The Chill Out Zone and Young People's Forum is organised and managed in ways that redress the feeling that many young people have that choices are made for them. Some young people feel they have little control over their situation. The Forum puts young people in the driving seat. The discussions they have and the decisions they make shape and influence the services they are actually using. No difficult subjects are swept under the carpet. It makes sense that they take it seriously.

The Grassroots Programme engages and empowers local people to lead and develop an infant and maternal health programme. Forty-six local volunteers deliver and develop the programme. The volunteers' training gives both the local people on the programme and the volunteers the confidence and skills to take control over the decisions they make. The improved social networks mean that both volunteers and young mums are much more involved in their own communities.

Parent Councils in nurseries are an important community asset which has been engaged by an HLC through identifying parents on each Parent Council who have volunteered to be a 'health link' to the HLC. The two way flow of information and mutual support in this new network and the confidence it has given the parents to suggest new health improvement activities and seek support for them is making a significant contribution to the wellbeing of the children and their families.

Mind Yer Heid is an anti-stigma activity which engages the community in dialogue about mental health. Over 3 months, more than 400 people were engaged in creating canvas art that expressed their thoughts and feelings about mental health. The HLC worked with existing groups in nurseries as well as other age groups and sections of the community, and set up stalls in public areas to engage with families and general population. The resulting art work is exhibited as part of Scotland's Mental Health Arts and Film Festival. Many participants enjoyed the opportunity to express their thoughts and feelings, and for others it took courage to do so. Families with young children were able to explore a sometimes difficult issue in a safe environment using a fun medium. Canvases by young children were exhibited and valued alongside those painted by others, including adult artists. It demonstrates the ability of the youngest members of our community to participate, share and shape the knowledge and attitudes of the community as a whole.

Healthy Mums Programme works with women from 12 weeks of pregnancy through 2 years post-birth. The core activity is the provision of free fruit and vegetables. Additionally, mums can access a range of skills-based courses including Baby Massage and Baby Yoga, and a relevant knowledge-base around stress management, healthy eating, coping on a budget and so on. This programme is a success largely due to the local volunteer-run Fruit Barra which has been established by the HLC in the community at various venues over nearly 16 years. The volunteers are all members of the local community and have local knowledge and personal experience which is shared with the pregnant women in an informal manner while they are collecting their fruit and vegetables. This complements and supplements the clinical service provided by the NHS, and helps mums who may feel isolated to recognise and access the range of networks and support available around them.

These projects build community networks and enhance trust within communities. They try to help people enhance their skills for managing their lives and their work is shaped by dialogue with those involved in their activities.

Another project which seeks to develop assets in those involved in it is a small, independent theatre company based in Glasgow. Theatre NEMO works to promote good mental health and wellbeing through the creative arts by engaging and supporting vulnerable individuals within the community, psychiatric hospitals and prison. Clients in the main are those from areas of high deprivation, where instances of mental ill health are more prevalent, and who have difficulty accessing mainline services. The founder of Theatre NEMO describes the work of the group in these terms:

"Our aim is to break down stigma and isolation and to provide opportunities to explore individuals' potential to achieve a better life:

We believe that Theatre Nemo is unique in Scotland in the inclusive nature of its work with vulnerable people. Other groups work in the mental health field but rarely offer the diverse activities that really engage hard to reach people. One of our strengths is that we really motivate people and have great attendance records. Very seldom does anyone drop out of a project.

These projects help people who have lost skills through life events to re-connect with their community, increase confidence. They encourage people to believe in themselves, develop new skills, developing a 'want to learn' attitude which will improve motivation to take up other social or education opportunities. They encourage interaction within the community and support recovery. Being involved and taking part in our performances and talks which we take out to the community and to policy makers has helped give people a better understanding of social and mental health issues. We break down some of the taboos, barriers and fears which surround people in difficult situations."

One of the most economically deprived communities in the UK also has one of the lowest life expectancies. Yet, through effective community engagement, people in Bridgeton have developed great insight into the processes likely to enhance their health and wellbeing. They provided the following thoughts on health improvement for this report:

"Typically, consultation with our community has always been carried out by men wearing suits and carrying clipboards. Our negative perceptions of the process were severely challenged when we met the North East Neighbourhoods Planning Team from Glasgow City Council. They came to us with innovative ideas about meaningful consultation instead of the tokenistic process we had come to expect. We were surprised when they invited us to lead on consultation for the East End Local Development Strategy ( EELDS). They asked us to assist in designing the process of community engagement and associated events. We became facilitators in the process, active members, making decisions. For us this was utterly empowering. Throughout the experience we were introduced to new ideas about health and planning. Not only did this experience encourage us to explore the effects of the living environment on our own individual lives, but we began to consider the wider effects on the community as a whole. With growing knowledge and understanding we began to ask questions, challenge opinions and prejudices and we considered how we could influence regeneration in ways that would lead to positive change for our communities.

If we had been asked, just a year before, what the social determinants of health were, we would have assumed the questioner was from another planet! However, during 2008, after the EELDS was published we were invited by the National Social Marketing Centre in London to make a film of our involvement in planning for health as an example of best practice for the rest of the UK!

At the conclusion of the EELDS, we became more involved in regeneration through volunteering, study and even employment. Several of us gained degrees in Community Development. This was a journey some of us were making anyway. However, our involvement in EELDS gave us a new perspective, better vision and growing knowledge which held us on this pathway and opened it up to others.

We are now actively involved with the Clyde Gateway Urban Regeneration Company and have had the opportunity to see our work influence new projects and ideas. As our confidence and abilities have grown, so, too, have our relationships with the very professionals we previously eyed with suspicion. We are now involved in the Equally Well project to help develop a community version of Healthy Sustainable Neighbourhoods Model and we are developing new ideas for involving people in other projects.

Our communities are our homes, lives and everything we are. If we concentrate on the problems, we'll create them. If we visualise and focus on how our environment can be, then we create a healthier mindset which in turn improves our wellbeing. We believe in that. Now we need to help others believe it too. We are not apathetic people, to blame for our environment. We are community assets, able to contribute to the improvement of ourselves and our areas. If we are to be labelled, lets label ourselves with positive words such as contributors, assets, useful worthwhile, giving, involved, able and, of course, HEALTHY!!!

We are no different from those in more affluent areas, we just swim in a rougher part of the river."

Figure 6: infant mortality in Scotland compared to Scandinavian countries

Figure 6: infant mortality in Scotland compared to Scandinavian countries

Achieving a step change in health

I have argued that we need to develop an approach to health improvement which does more to unlock the assets within individuals which create a sense of control and wellbeing. Experience shows that creating momentum behind such a movement takes time. To achieve a real change in health status, it will probably be necessary to combine a salutogenic approach with a targeted programme of interventions provided by statutory agencies. These interventions would be aimed at ensuring that people who want to improve their health have the necessary opportunity to do so.

Figure 6 compares infant mortality in Scotland with infant mortality in Scandinavian countries. Although Scotland has, by a narrow margin, the lowest infant mortality amongst the UK countries, it still has a higher mortality than any of its Scandinavian neighbours.

The significantly lower mortality in some of the Nordic countries has been achieved by a series of actions which have caused a rapid decline in the rate of deaths in the first year of life.

A rapid reduction in infant mortality might be achieved by a number of interventions. Early access to antenatal care, stopping smoking or consuming alcohol during pregnancy, breastfeeding after birth and support for mothers who struggle to look after their children will all contribute to lower infant mortality. Consistent application of evidence-based interventions for every child in every family would have a significant impact on infant mortality.

Another example of a step change is the decline in smoking in the North East region of England. Between 2004 and 2008, smoking rates in Scotland fell by 1% and in England by 4%. In NE England, it fell by 8%, overtaking the Scottish incidence. (Figure 7)

This fall in smoking rate has been achieved by a consistent and comprehensive application of appropriate interventions. Basically, North East Regions has achieved these results because it has tried harder to do the right thing.

Figure 7: smoking rates - a step change in NE England

Figure 7: smoking rates - a step change in NE England