Annual Report of the Chief Medical Officer 2012 - Population Health and Improvement Science

CHAPTER 1

Creating Health

In my last annual report, I described some of the social theories underpinning the idea that health can be created by the way society is organised and by the way individuals interact with others in society. The broad term applied to those theories is "salutogenesis". At a recent conference, Don Berwick, the founder of the Institute for Healthcare Improvement and one of the world's leading thinkers on health systems, described salutogenesis as possibly the way we will measure the effectiveness of healthcare in the future.

So, what is "salutogenesis?" Mother Theresa once said that she would not join a march against war but would join one for peace. Such a march, she argued, would not only empower people to end war, but also help them create the basis for peace. In her view, the process of creating peace was different from merely ending war. In the same way, the concept of salutogenesis implies that professionals - and not just health professionals - should work to create health rather than simply focusing on treating or preventing disease.

The word "salutogenesis" comes from the Latin salus meaning health and the Greek genesis meaning origin or source. It is a term which was originally coined by the American sociologist Aaron Antonovsky ^[1]. He developed the concept in the course of studies of how some people are able to manage stress and stay well while others are damaged by continuous exposure to stressful events. He observed that, while stress is ubiquitous, not all individuals have negative health outcomes in response to stress. Instead, some people achieve health despite their exposure to potentially disabling stress factors. He set out to discover the reasons some were protected while many succumbed to difficult circumstances.

He produced what he considered the most likely explanation for this observation in his book, "Health, stress and coping" ^[2]. In it, he postulates that, in early life, we acquire a set of psychological and social resources which allow us to manage our way in the world. These resources, he suggests, include insight and intelligence, social networks, material resources and cultural anchors such as belonging to a church or social organisations or even simply having a large circle of friends.

Together, these resources allow an individual to feel that he has insight into the events of his life, that he feels he can influence them and that he can be optimistic that things will work out as well as can be expected. He described this psychological outlook as having a "sense of coherence". Individuals who have a strong sense of coherence, he suggested, would be more likely to create and maintain a high level of health.

Antonovsky's social theories have been tested in a number of settings. He predicted that individuals who did not acquire a sense of coherence at an early age would experience a state of chronic stress and this state would reduce their chances of being healthy. The literature on the relationship between adverse social conditions and chronic elevation of markers of stress is extensive ^[3] and shows a clear, strong relationship between socioeconomic status and a range of biochemical changes which are predictors of a range of problems.

The salutogenic approach to health implies that it is insufficient to try to prevent disease if the intention is to create health. Indeed, the idea of disease prevention seems overly idealistic since it implies a belief that humans are basically all healthy until they encounter some external cause of disease. This would suggest that action to increase health is unnecessary until some external cause of disease is encountered. Clearly, this idea is unrealistic. In recent times, it has become accepted that action is required by individuals continually to keep moving towards a state of better health through techniques such as exercise. The assumption that health professionals, using a pathogenic model need only react to situations that threaten to cause disease is gradually being eroded as professionals respond more holistically to the needs of people. They are becoming more proactive in supporting people create better health better health for themselves through managing all aspects of their lives more successfully.

At its heart, the salutogenic approach focuses on the maximisation of those assets which create health, wellbeing and successful lives for individuals. The traditional pathogenic approach focuses more on avoiding problems than on enhancing potential.

Creating wellness is not just a matter of creating health

The salutogenic approach sees health creation as a matter of capacity building. Health is created by being in control of one's life and by developing a sense of being able to navigate the complex challenges of modern existence. However, the skills and attributes that allow us to be resilient in the face of challenging events and support the creation of health are also the same qualities that produce success in other areas of life. They are not health specific. Understanding how the world works and feeling confident that we can cope with events also allows us to be successful in education, in relationships and in the workplace. Failure to respond appropriately to external events leads to increased risk of failure in all areas of life.

Recognition of the way in which positive outcomes across many domains of life are connected to each other and to a salutogenic outlook leads us to the view that we should not restrict efforts to simply improving health. Instead, we believe that salutogenic approaches can be used to strengthen many aspects of life in modern Scotland. These include making Scotland the best place in the world to grow up, reducing offending and reoffending by young Scots and in helping older Scots age in ways that enhance and prolong their wellbeing.

Improvement science - a means of delivering salutogenesis?

Critical to the successful implementation of this approach, however, has been the use of improvement science ^[4]. Many reports and policy documents have been written over the years that have been aimed at improving outcomes in the Scottish population. Some have had great impact but many have, at best, been of limited benefit. The introduction of implementation methods based on improvement science techniques has been revolutionary in terms of changing the complex system of health care in Scotland, improving its quality and safety. The use of such techniques to improve population health has the potential to be equally revolutionary.

Improvement science has been defined as a way of improving decisions about the organisation and delivery of healthcare by using systematic observation and experimentation to produce generalisable knowledge which can then be applied.

As used in Scotland, it involves "The Model for Improvement", a tool developed by Associates in Process Improvement (www.apiweb.org). The model is a means of accelerating the pace of change in a complex system. It has been used extensively in improving health care processes and outcomes in many different settings. It involves getting a team together to answer 3 basic questions.

Figure 1 The model for improvement

What are we trying to accomplish?

Improvement requires setting aims. The aim should be time-specific and measurable; it should also define the specific population of patients or other systems that will be affected.

How will we know that any change is an improvement?

Teams use quantitative measures to determine if a specific change actually leads to an improvement.

What changes can we make that will result in an improvement?

Ideas for change may come from the insights of those who work in the system, from change concepts or other creative thinking techniques, or by borrowing from the experience of others who have successfully improved.

Once answers to these questions are agreed, the proposed changes are tested in a Plan-Do-Study-Act (PDSA) cycle to see if the changes work in real life settings. By planning change, trying it, observing the results, and acting on what is learned, action-oriented learning is embedded in the system. The way in which this method is applied to improving the experience of young children in Scotland, reducing the chances of young people entering the criminal justice system and supporting older Scots remain well as they age will be described.

The team designing and testing change includes those involved in the delivery of care and the agreed aims are set to ensure that a timely difference to the quality of that care is delivered. It requires a close partnership between the people who are making decisions about how best to organise and deliver care and those who use health services. In short, these improvement methods involve managers and clinicians in making better use of evidence in making decisions, and researchers to focus on the usefulness of their work.