Working Together for a Healthier Scotland

Summary and Invitation to Comment

Good health is more than the absence of disease. It has to do with the way we live, the quality of our life and our environment. That is what public health - and this Green Paper - is all about.

Overall the health of Scotland is improving. The drive to act for our own health has had some impact. Many fewer adults smoke, and we are now less likely to die from heart disease or cancer in middle age. But the improvement has neither matched progress by similar countries nor reached all Scots equally. Smoking, poor diet, too little exercise and misuse of alcohol and drugs stand in the way of better health: their roots lie partly in poverty, unemployment, poor housing and poor environment. Ill-health is not a problem for patients or health services alone, but impacts on family and community life, and on local services.

Care for our own health throughout life is a strong theme in this Green Paper. But broader changes in how people live - which they are not in a position to control - are as important. True public health policies are embedded in action to improve our quality of life and protect our environment, to tackle social exclusion, in improving housing and educational achievement, in addressing poverty and unemployment and in the re-structuring of the National Health Service as a public health organisation with health improvement as its main aim. It is the business of Government - all of Government - and all those who are in a position to influence and contribute to our quality of life.

The policy changes heralded by this Green Paper will link these broader programmes to their impact on our health and well-being; encourage stronger collaboration between health services and the many organisations whose actions impact on our health, especially Scotland’s local authorities; and give priority to the communities and groups that have the worst health.

This Green Paper seeks views from the public, from councils and agencies, from health bodies, voluntary organisations, employers and employee representative organisations, on how we can work together towards better health and well-being. In our White Paper later this year we expect to favour practical policies for joint action that will be widely supported, and likely to be effective. More than anything, however, this new drive towards a healthier Scotland demands a carefully planned approach with new ways of thinking and working together, particularly at local level.

Making Our Efforts Count

Making an impact on public health means acting on the life circumstances that underlie poor health, including a worthwhile job, a decent home, a good education and a clean environment. It also includes personal investment in healthy lifestyles, backed by sound policies and, more rarely, regulation. And we must target the places where people are, including schools, workplace and community settings, and the Health Service. Success will require strong partnerships between health professionals and other local bodies within a national framework. (paragraph 95)

So our proposed priorities are improving life circumstances, such as tackling deprivation and encouraging individuals to adopt healthier lifestyles by not smoking, by eating for health, taking greater physical exercise, and avoiding alcohol and drug misuse. (paragraph 81)

We propose, for Scotland’s main ‘illness’ priorities, coronary heart disease and stroke, cancer, mental health, sexual health (including teenage pregnancies and HIV/AIDS), dental and oral health, and accidents. (paragraph 46)

For each of these priorities, tackling inequalities will be our first challenge.

Working Together

The Green Paper suggests ways of working together and invites comments and further suggestions for action. Our main proposals are:

• Health impact assessments for use in central government and its agencies and in local government to consider the consequences for health of all major policies. These assessments should be effective without being overbearing. Guidance is sought on where and how they are best applied. (paragraph 103)
• An expert working group, chaired by the Minister for Health, to draw up a strategic framework for strengthening and regenerating communities, particularly disadvantaged communities. (paragraph 108)
• Broad programmes for area regeneration in places where Scotland’s health is poorest. How can we achieve best results through the work of Priority Partnership Areas and the urban partnerships? (paragraphs 113-117)

Tackling Lifestyles that cause Illness

Changes in lifestyle will be far more effective, when linked to steps that address the root causes of ill-health. Major challenges remain and views are invited on:

• Changes in the regulation of tobacco will be set out shortly in a separate White Paper. How can smoking be stopped, especially by young people and those living on low incomes who paradoxically smoke more and are least likely to stop? (paragraph 121)
• How can harm from excessive drinking be reduced? (paragraph 122)
• How can we address both health and community safety issues which derive from drug misuse, particularly in areas of high use? (paragraphs 123-128).
• Should preventive work aimed at young people target alcohol, illegal drugs and tobacco separately, together or through more general lifestyle approaches? (paragraph 128)
• Does the new emphasis on tackling health inequalities, and boosting local health networks give opportunities for improving diet, beyond the extensive plans in the 1996 report "Eating for Health"? (paragraphs 129-130)
• How can we stimulate physical activity in Scotland, particularly by those currently taking little or no exercise? (paragraphs 132-137)
• What more can we do to protect children’s teeth? (paragraphs 139-142)
• Reducing teenage pregnancies, improving mental health and tackling domestic violence are health issues that draw, and impact broadly, on society. How can we achieve greater effectiveness? (paragraphs 143-146)
• Accidents still cause much disablement and death especially in poorer areas. How can these accidents be prevented? (paragraph 150)
• Infectious diseases still pose a threat in Scotland. The Government propose a review of existing public health legislation. (paragraphs 151-153)
• Other countries face similar problems, but enjoy better health. What can we take from their approaches which can be made to work here in Scotland? (paragraph 97)

Completing the Jigsaw

Many things that local authorities do affect health and local policies and strategies need to take this into account. Our proposals on which views are sought are:

• Directors of Public Health, as the designated medical officers for local authorities, should help them assess the health impact of local policies, and be co-opted, or appointed, to appropriate council committees (for example, housing, social work and education). (paragraph 154)
• The Scottish Office should fund a public health post in COSLA, to develop good practice and to help to co-ordinate healthy local authority policies. (paragraph 157)
• The Health Education Board for Scotland, the Scottish Consultative Council on the Curriculum and COSLA should set up a small specialist unit to help develop health promoting schools throughout Scotland. (paragraph 180)

Under proposals launched in December 1997 in the White Paper Designed to Care: Renewing the NHS in Scotland, Health Boards, as public health organisations, will be responsible for securing health improvement in their area. Health Boards, NHS Trusts and primary care services already work together to draw up health improvement programmes. Many professionals employed in the NHS, from public health doctors, through hospital staff, family doctors, health visitors, retail pharmacists and health promotion officers have relevant skills to work with the public and will be expected to target resources to help people in disadvantaged communities.

• How can the overall contribution of the Health Service be maximised? (paragraphs 158-175)
• How, in particular, should the Health Education Board for Scotland, which leads health education, best contribute? (paragraphs 176-184)
• How can the explosion in information technology be harnessed to health improvement? (paragraph 182)
• Other parts of Scottish life include direct contributions to health. How does industry consider the public health impact of its actions both in the market and in the workplace? (paragraphs 186-190)
• How can the distinctive role of the voluntary sector assist health improvement? (paragraphs 191-194)

Indicators, Targets and Research

The success of our policy will be measured by our impact on health in Scotland. Indicators and targets must be seen as relevant and credible, and be owned by the people who work towards them. Before agreeing them, with the help of an expert group, the Government would welcome views on the priorities to set, the indicators and targets which should follow, and the period that they should cover. Our Green Paper suggests health outcome targets for coronary heart disease and stroke, cancer, teenage pregnancy, dental and oral health and accidents. Lifestyle targets are proposed for smoking, alcohol misuse, eating for health and physical activity. Views are sought on whether targets should be set also in the mental health, HIV/AIDS and drug misuse fields. (paragraphs 196-212)

Good research is vital to guide the development of effective public health policy. What priorities should be set for a research programme to inform, guide and evaluate Scotland’s health efforts? (paragraphs 214-218)

Commitment

The Government are committed to tackling public health on a broad front, enlisting the help and support of all those who can make an impact, including members of the public and local communities. Please help us work together towards a healthier Scotland through your ideas, comments and commitment.

Comments should be sent by 30 April 1998 to The Public Health Policy Unit, The Scottish Office Department of Health, Room 433, St Andrew’s House, Edinburgh EH1 3DE, marked "For the attention of Mrs J Niven". The Government may wish to publish these comments or make them available to others. You are asked to make it clear if you would prefer your comments to be treated in confidence.