Review of targets and indicators for health and social care in Scotland

The Challenge

9. Scotland has long standing problems of health and wellbeing. In a comparison of life expectancy trends in 16 Western European countries, Glasgow Centre for Population Health showed that Scots had the lowest life expectancy of all the countries studied ^[2] . It was not always so. The study gathered data as far back as 1861. For most of that time, the life expectancy of Scots was comparable with our neighbours. It is only in the past few decades – since around the 1960s – that we have drifted to the bottom of the Western European league.

10. Closer examination of the data shows that much of the problem is associated with socioeconomic inequality. The life expectancy of affluent Scots has increased at a much faster rate than that seen in the most deprived areas. As a result, growth in average life expectancy across the population has slowed. Inequality can, however be defined in ways other than life expectancy. Inequality in terms of opportunity to flourish due to the way society causes disability for certain groups, for example, is a real risk requiring public services to be assiduous in assessing and meeting need for support to disabled citizens.

11. Widening socioeconomic inequality has been attributed by some to industrial policy in the latter half of the 20 ^th century. Parts of Scotland experienced considerable loss of jobs in traditional industries. At the same time individuals were being uprooted and moved to new towns and districts as post war housing reforms were taken forward. Social cohesion was eroded. Whatever the reason for widening inequality, it is clear that without efforts to narrow the spectrum of socioeconomic status, improvements in our life expectancy will be slow.

12. How we might achieve this aim is not entirely straightforward. Conventional thinking might suggest that, since heart disease and cancers are the commonest causes of death, reducing smoking, improving diet and encouraging exercise should be the main strategies used to improve wellbeing in Scotland. Undoubtedly these interventions are important and efforts to achieve better heart health and cancer prevention should be intensified. However, the causes of inequality in life expectancy are more complex. Deaths from heart disease and cancers mostly occur in the elderly and it has been shown that inequality in mortality is widest in age groups which are younger than those most affected by heart disease and cancer. The causes of greatest inequality in younger people are not principally heart disease and cancer but deaths due to drugs, alcohol, suicide, accidents and violence. If we are to improve life expectancy and wellbeing in Scotland up to levels comparable with the rest of Western Europe, we need to do more than provide smoking cessation services, important as they are. The causes of inequality require attention to the emotional, psychological and social needs of people as much as they require attention to the causes of illness.

13. Current thinking on transformational change for wellbeing would support us adopting a life course approach. WHO Europe, in 2015, advocated such an approach in its Minsk Declaration ^[3] . This document outlines a set of actions, which might be taken by governments in their efforts to deliver the Sustainable Development Goals. It states that: "a life-course approach for health and well-being builds on the interaction of multiple promotive, protective and risk factors throughout people's lives. This approach adopts a temporal and societal perspective on the health of individuals and generations, including intergenerational determinants of health. A life-course approach is an investment in health and well-being. The adoption of the life-course approach across the whole of government would improve health and well-being, promote social justice, and contribute to sustainable development and inclusive growth and wealth in all our countries." Essentially, such an approach involves acting in early life and at major transitions to support individuals.

14. The critical importance of early years in determining future wellbeing is particularly identified by WHO.

"The earliest years of life set the tone for the whole of the lifespan. A child that is cared for, nurtured and stimulated, appropriately fed and protected early in life, grows into an adult with greater life chances, better cognitive and physical development, superior educational achievement, and greater productivity. Investment in early childhood development, and protection against toxic stress and dangerous environmental exposure at critical points of development are among the most cost effective policy choices available to governments."

15. This review argues that, if we are to deliver the policy objectives of supporting the population of Scotland to flourish through reducing inequality and improving wellbeing, we need to create a society which allows all individuals, regardless of ability, ethnicity, economic or social status to be resilient, be in control of their lives and feel they have a sense of purpose. Individuals with these characteristics are less likely to fail in education, engage in offending behaviour, be unemployed and more likely to adopt healthy behaviours. If these outcomes are indeed the policy context for this review of targets and outcomes, we need to consider carefully if our present approach is fit for purpose.