Changing children’s lives-how to deliver concerted action

Edinburgh14th September 2012

Three phases

1. Assemble the knowledge about the problem and the evidence for change

2. Build the will to do something about the problem

3. Chose a method for change and deliver at scale

Life expectancy trendsLife expectancy: Scotland & other Western European Countries, 1851-2005

Source: Human Mortality Database

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Infant mortality trends 1848-2000

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1840 1860 1880 1900 1920 1940 1960 1980 2000

Infa

nt m

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lity

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bir

ths

Source : Birth Counts, 2001

England & Wales

Scotland

All cause mortality in Scotland in European context

Males age 1-14 years

Age

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d m

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lity

per 1

00,0

00

Male mortality 15-75Scotland and 15 other European countries

Female mortality 15-75Scotland and 15 European countries

Workers in the 1950s

Walsh, D. et al. Eur J Public Health 2010 20:58-64; doi:10.1093/eurpub/ckp063

Male life expectancy at birth West Central Scotland and 10 post-industrial regions

Post industrial regions of Europe

Do social conditions determine the incidence of disease? For centuries they have and they still do in

the developing world–Plague, leprosy, polio, diphtheria,

typhoid, tuberculosis–BUT in the developed countries

It is how we respond to social conditions which largely determines our risk of chronic ill health

Income deprivation - LiverpoolLiverpool LSOAs: income deprivation distribution

Source: DWP

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Total city: 24.6%

Income deprivation - GlasgowGlasgow merged DZs: income deprivation distribution

Source: GCPH, based on SIMD/DWP data

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Total city: 24.8%

Standardised mortality rates by cause, all ages: Glasgow relative to Liverpool & Manchester

All ages, both sexes: cause-specific standardised mortality ratios 2003-07, Glasgow relative to Liverpool & Manchester, standardised by age, sex and deprivation decile

Calculated from various sources

112.2 111.9126.7

248.5

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All cancers(malignantneoplasms)

Circulatory system Lung cancer External causes Suicide (inc.undetermined intent)

Alcohol Drugs-relatedpoisonings

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ndar

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ratio

Source: Walsh D, Bendel N., Jones R, Hanlon P. It’s not ‘just deprivation’: why do equally deprived UK cities experience different health outcomes? Public Health, 2010

Aaron Antonovsky 1923-1994

“.....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."

Sense of coherence....

For the creation of health....

....the social and physical environment must be:

Comprehensible Manageable Meaningful ......or the individual would experience

chronic stress

00-046

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Months of Orphanage Rearing

*linear trendline

Evening Cortisol Levels Increase withMonths of Orphanage Rearing *

The Founders’ Network

STRESS AND GRADE OF EMPLOYMENT: MEN

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/l Higher GradeLower Grade

Salivary Cortisol

Time of DaySteptoe et al. 2003, Psychosomatic Medicine, 65, 461-470

Depcat % smokers Never-smokers Smokers

1 36.8 0.71 1.42

2 35.9 1.00 2.34

3 39.1 1.11 2.25

4 44.1 1.21 2.44

5 46.6 1.13 2.53

6 49.3 1.25 3.07

7 55.5 1.48 3.29

Environmental determinants of inflammatory status

CRP (median) mg/dl

affluent

deprived

Inflammation in plaques

Inflammatory cells

MMPs, IL-6, IL-15, IL-18, CRP

Lumen

Core

Cap

Thin Fibrous Cap

InflammatoryCells

SMC apoptosis

Degradedmatrix

Unstable

cytokines MMP

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Q1 : <0.66 mg/l

Q5: > 4.18 mg/l

Years in study

% diabetic

CRP and cumulative risk of type 2 diabetes

Freeman et al. Diabetes 2002,51;1596

Adipocyte programming insulin resistance, inflammation and ALP

Adipose stores

NEFAs

liver

CRPSAA

IL-6/IL-6sR

TNF-a/ TNF-a sR-I

triglyceride

Low HDLsmall LDL

AtherogenicLipoproteinPhenotype

Pro-inflammatorystate

skeletal muscleInsulin resistance

Persistence hunting

Adverse childhood events study Physical/sexual/emotional abuse Neglect (physical/emotional) Domestic substance abuse Domestic violence Parental mental illness Parental criminality

Adverse childhood events risk of alcoholism

Hillis et al 2011

Adverse childhood eventsrisk of perpetrating violenceBoys experiencing physical abuse

Duke et al 2010

Risk of heart disease and early adversity

Health Deficits approach Focuses on problems, needs and

deficiencies in a community such as deprivation, illness and health damaging behaviours. It designs services to fill the gaps and fix the problems. As a result, communities can feel disempowered. People become passive recipients of services rather than active agents in their own lives

Health Assets A health asset is any factor or

resource which enhances the ability of individuals, communities and populations to maintain their health and sustain wellbeing. The assets can operate…as protective and promoting factors to buffer against life’s stresses

Morgan 2009

Strengthen Community Actions

Health promotion works through concrete and effective community action in setting priorities, making decisions, planning strategies and implementing them to achieve better health. At the heart of this process is the empowerment of communities - their ownership and control of their own endeavours and destinies.

The pathology of poverty

24th European Congress of PathologyPrague

11th September 2012

A System

Functions of a system To allow a few people to control many–eg. Captain of a ship

Allows production of a great deal of the same thing–Goods or services

Needs to create consumers or clients–ie Creates need

The multi service system

Associations of citizens

Decide what the problems areDecide how top solve themOrganise to implement the solution

Social connectedness 148 studies comprising 308,849

participants, high levels of social integration conferred a 50% increased likelihood of survival.

Complex patterns of social integration conferred a 90% increase in survival.

Simple indicators such as living alone versus living with others conferred a survival benefit of only 19%.

SGLAsNHS3rd

Sector

Enhancing social connectedness

1. Light the fire

2. Build communitie

s

Help to connect people Coproduction

CoproductionThe conventional delivery model does not address underlying problems that lead many to rely on public services and thus carries the seeds of its own demise. These include a tendency to disempower people who are supposed to benefit from services, to create waste by failing to recognise service users’ own strengths and assets, and to engender a culture of dependency that stimulates demand. Co-production has the potential to transform public services so that they are better positioned to address these problems and to meet urgent challenges.

Early years Youth alcohol and offending Rehabilitation of offenders Employment and local

entrepreneurism Physical fitness Support for the elderly

A life course approach?

Improvement science W Edwards Deming (1900-1993)

– “In God we trust, all others must bring data”– “By what method? Only the method

counts.” Don Berwick

– “Some is not a number. Soon is not a time.” Scottish Patient Safety Programme

– “By how much and by what method?”

Executing the change

There are many change theories and models. We must choose a small number of improvement methods and stick with them for the long haul.

They must all be based on the simple formula of aims/measures and changes.

Our selection may be;CollaborativesBenchmarking and competitionUser/ Community empowermentPerformance management

The choice must be explicit and evidenced.

Agree outcomes– For pregnancy, early development and

preparedness for school Agree interventions to achieve these outcomes

– Five or six evidence based interventions for each stage

Apply interventions consistently across the whole population

Measure progress and react to the data

An early years collaborative

Outcome Aims Mortality: 15% reduction by 2015 Adverse Events: 30% reduction Ventilator Associated Pneumonia: 0 or 300 days between Central Line Bloodstream Infection: 0 or 300 days

between Blood Sugars w/in Range (ITU/HDU): 80% or > w/in

range MRSA Bloodstream Infection: 30% reduction Crash Calls: 30% reduction

Scotland HSMR – 9.3% reduction

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Standardised Mortality Ratio (SMR) Regression line

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% compliance with multi-disciplinary rounds and daily goals

74%

93%

19% improvement

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VAP rate (per thousand ventilator days)

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61% reduction

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General ward C.Difficile rate(per thousand patient days)

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90% reduction

Jimmy Reid 1971

Rectorial Address “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....”