Public Health Annual Report

2012

Doing Things Differently: Doing Different Things

NHS Shetland Public Health

Department

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A recipe for mackerel

Catching your own fish isn‟t essential to this recipe; it just adds to the fun. The key to

success is sharing fresh, tasty food with friends and family; all pitching in and having

a good time.

You will need:

A bunch of friends, family, neighbours (preferably of different generations)

A boat, fishing lines and some bait (alternatively you can use shop bought fish

– but it isn‟t quite the same)

To accompany the fish:

fresh veg

a little wine

laughter – to taste

Step 1: Catch your mackerel.

Choose a fine day, take your friends and family off on the boat and catch your fish.

Relax, enjoy yourselves, have fun. Let the older generation teach the younger

generation how to fish.

Step 2: Cook

Prepare your fish in whatever way you want: add some seasoning, some spice or

leave it as it is. Barbeque on the beach, stick under the grill, fry in the pan - it‟s up to

you. All join in and help cook the food.

Step 3: Serve

Add some fresh veg, some tatties or brown bread. Serve with a small glass of wine if

you like, iced water for the bairns.

Step 4: Eat

As step 1: relax, enjoy yourselves, have fun

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Table of Contents

Introduction .................................................................... 4

Public Health Ten Year Plan: Changing the World (Executive Summary) ..................................................... 4

Improving Health – how far have we come? .................. 7

Asset-based approaches – not the „nanny state‟ ......... 27

The Big 3...and the even Bigger Questions .................. 38

Smoking ……………………………………………………………………………………..39

Alcohol ……………………………………………………………………………………….47

Obesity ……………………………………………………………………………………….56

Poverty & Inequalities .................................................. 66

A personal perspective ................................................ 79

Now it‟s over to you........... ........................................... 82

Acknowledgment

As usual, I am indebted to the contributions and help given by colleagues both within the Department of Public Health, across NHS Shetland, and in partner organisations including Shetland Islands Council, other Community Planning Board partners and other organisations working for the improvement of health in Shetland. In particular my thanks go to: Kathleen Anderson, Kim Govier, Wendy Hatrick, Andy Hayes, David Kerr, Dr Susan Laidlaw, Elizabeth Robinson, members of the Health Improvement Team, and colleagues and clients from Community Alcohol and Drug Service Shetland for the Recovery quotes.

Dr Sarah Taylor Director of Public Health

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During 2011/12 the Public Health Department decided that the time had come for a change.

We could carry on doing the things we have traditionally done, making slow but steady

progress, or we could be more ambitious, set our sights higher, do things differently. We set

down these thoughts in our Ten Year Plan: Changing the World. The executive summary

below describes our reasons for change and a radical vision for action. The rest of our

Annual Report gives more insight into how we might achieve this.

Public Health Ten Year Plan: Changing the World

(Executive Summary)

This strategy was written to answer the questions we posed in the 2011 Public Health

Annual Report: what can we achieve to improve health in Shetland? How much should we

invest? Where should we focus our effort? Are there different approaches that we should

take?

It attempts to set out a bold and radical vision for the future of Shetland in which people live

longer, in good health, and where everyone contributes to the communities that they live in.

Our strategy looks longer term, is more ambitious, thinks more holistically about health. We

need to make better use of the resources we have, so we need to do things better – be

more efficient, build our knowledge and experience of what works, and have a bigger

impact in what we do. We want to move beyond just focusing on specific „unhealthy‟

behaviours, to take a more positive approach to improving our health both personally and

as a community.

The strategy summarises the case for investing in health improvement, with evidence for

savings to be made on health (and other) services through the prevention of ill-health. It

sets out the current context of non-sustainable public sector services, and reducing

budgets. It develops the theme of 'doing things differently' through early intervention, asset

based approaches, developing resilience at personal and community levels, with an

emphasis on tackling inequalities - not widening the gap.

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The strategy then sets out the longer term outcomes we are working towards, and how we

can achieve them, using familiar themes that illustrate different public health approaches:

Smoking:

Early intervention that means people don't start to smoke in the first place or helps

them quit before it becomes an ingrained habit or addiction.

Using incentives to help people stop smoking, which might be about motivation in

pregnancy or around children, or personal goals and rewards.

Community action - developing and supporting a non-smoking culture.

Obesity:

Tackling the stigma and prejudice around being underweight and overweight

Tackling the factors which cause and contribute to being an unhealthy weight.

Taking direct action to help people to be more active and to eat more healthily; both

individually and at policy and community levels.

Early intervention with families and through nurseries and schools to prevent

childhood obesity, which includes working with pregnant women, promoting breast

feeding, and working directly with children and families to tackle weight issues

successfully.

Alcohol:

Changing the culture on drinking to tackle harmful drinking and make it easier for

people with a problem to come forward and ask for help.

Working in partnership with the Licensed Trade, police, environmental health to

promote sensible drinking.

Early intervention through programmes such as Alcohol Brief Interventions to flag

risky drinking at an early stage and offer appropriate help and support for people to

change their habits.

Poverty & Inequalities:

Although Shetland is a relatively prosperous community, and we have, for the most part, a

good quality of life, there are still people living in Shetland in poverty, families who are not

able to access services, or get the help and support they need, and people who suffer from

discrimination and exclusion. Recent research by young people (“Poverty is bad: let‟s fix it!”)

has identified local issues and action to take: around lack of available/affordable transport,

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isolation, mental health and substance misuse problems, and stigma. The Fairer Shetland

programme is coordinating local work to tackle poverty and deprivation with priorities on fuel

and transport poverty, and dealing with the consequences of the current UK Welfare

Reforms. We need to tackle health inequalities alongside economic and social inequalities,

and our priorities on this are:

The Keep Well programme – focusing on our most deprived communities and households,

and delivering health checks and preventative services to people who are „hardest to reach‟

or who do not normally access primary care services.

Early Years – preventing problems in children and families before they become entrenched,

and building the capacity of families to give children the best chances in life.

Specific work on supporting parenting:

Improving children and parents‟ emotional resilience and mental wellbeing.

Intervening in domestic abuse in families with children to break the cycle of violence.

Long term conditions and chronic disease management:

o Recognizing that people who live with chronic disease are often the experts

on their diseases.

o Supporting them to manage their condition with appropriate advice and help.

o Promoting early intervention to prevent complications, and helping people to

be as independent as possible and reach their full potential, with whatever

condition or disability they have.

Other themes will develop as we do more work and these include: mental health and

wellbeing; developing resilience and the capacity of communities to help themselves; health

promoting health services.

This strategy won‟t have it all right, and it certainly doesn‟t yet have all the detail it needs.

But the evidence is that we could make a significant difference to the health of people in

Shetland over the next 10 years, with the right focus and effort. The challenge is to make

that happen.

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Improving Health – how far have we come?

How do we improve health? To answer in simple terms, we have to increase the things that

have a positive impact on health, and reduce the things that make health worse. However

the things that influence health are complex, and may be the result of a number of factors

including personal biology and genetics; environment; culture; socio-economic

circumstances; personal beliefs and attitude; and behaviour. To complicate things further,

what we mean by „health‟ and good health or poor health differs between individuals and

between different populations.

And, what we know about attitudes towards health and

influences on health has changed over the years, with

advances in science and changes in culture: it is hard

to believe that cigarette advertising used to use

endorsements by doctors about the pleasure of

smoking.

So, if the factors that affect health are complex, how

we influence these factors is also complex. Some

things can‟t be changed: such as family history and

genetic make upa and the fact that we all get older.

However, we can change attitudes and behaviour,

both at an individual level and population level – it may

take a long time and may not be easy, but can be done.

But just having the scientific knowledge and evidence which has the potential to change

attitudes and behaviour will not necessarily mean that things will change. As well as

acceptance by the population, there needs to be political will and often (but not always)

significant investment. However, as we discussed in last year‟s Public Health Annual

Report, there is a strong business case for health improvement as investing in improving

health which then prevents illness will save money in the long term.1 How Government

a Although scientific advances in gene technology may make this possible in the future: but this does bring with it ethical dilemmas.

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policy is influenced is very complex, with „health‟ being one factor to take into account

alongside economics, international relations and industry concerns. Consider, for example,

how valuable the alcohol industry is to both the treasury (through taxation) and local

economies, through employment.

In this chapter, we will look at some of the most important health issues, past and present,

and how successful, or otherwise, we have been in tackling them through traditional health

improvement approaches.

Clean water and vaccines

According to the World Health Organisation, the two public health interventions with the

greatest impact are clean water and vaccination.2 Implementing these lifesaving

interventions required scientific advances; investment of resources; legislation and changes

in people‟s beliefs and thinking. And, although we take these for granted now in our

society, there are still huge parts of the world where people do not have clean water, and

do not have access to vaccination. Even where high quality, safe and free vaccination

programmes are in place (as in the UK) people do not always access them, often because

of personal beliefs and attitudes.

We now do not think twice about the importance of clean water, and we are well aware that

„dirty‟ water may carry bugs that cause dangerous infectious diseases. Centuries ago, when

infectious diseases were very common, people believed that they became ill due to

changes in the air around the diseased tissue of people who already had the illness. This

was developed into the „Miasma‟ theory of disease which proposed that a vapour in the air

caused diseases. However, in 1854, a cholera outbreak in London led to a new theory: that

cholera was spread from person to person, by something from the

gut of an infected person being ingested by a healthy person. John

Snow, a doctor, investigated the outbreak by plotting the

geographical location of all the people with cholera and then linking

them with a particular water supply (from the „Broad Street Pump‟).

Further investigation involving London water supplies demonstrated

that cholera was associated with drinking water contaminated by

sewage. With the invention of the microscope in the 1670s, it was

possible to see micro-organisms in substances such as blood and

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water. But no association was made between these and illness in man until the late 1800s

when the Germ theory of disease was developed. 3

Once people knew that germs in the water caused disease, they could then take action to

either prevent people drinking the contaminated water (John Snow got the Broad Street

Pump handle removed); or clear the germs out of the water (the water treatment processes

that we use nowadays); or prevent the germs getting into the water in the first place

(sanitation - which is the provision of facilities and services for the safe disposal of human

sewage).

It is a similar story with vaccines. As long ago as 429 BC, the Greek historian Thucydides

noticed that those who survived a smallpox plague did not become re-infected with the

disease.4 In 900 AD, the Chinese started to use a simple form of vaccination called

variolation. The aim was to prevent smallpox by exposing healthy people to smallpox scabs,

by either putting some of the scab tissue under the skin or up the nose. Variolation started

to be used in England in the early 18th century; it caused mild illness, and sometimes death

but there was less smallpox in the populations that used it. This was at a time when

smallpox was the most infectious disease in Europe and killed 20% of the people infected.5

Then in 1796, Dr Edward Jenner discovered vaccination as we know it now. Initially he was

ridiculed, but eventually the scientific community, and the wider population, was convinced

that it worked and vaccination grew in popularity throughout Europe and then in America.

However in the late 1800s people started to oppose vaccination – not believing that it could

really work and that it took away people's civil liberties.6 These viewpoints still exist today,

despite all the evidence about the effectiveness of vaccines:

The eradication of smallpox has been a global immunisation success: now the only

smallpox virus left in the world is in a small number of secure laboratories.

Following the introduction of a vaccine against meningitis C in 1999, the number of

cases in Scotland has dropped by 90%.

In the UK, many diseases that were previously very common are now rare, such as

diptheria.

Even though safe and effective vaccinations are available, we have not yet been able to

control certain diseases such as measles. Although considerable progress has been made

globally, there are still some challenges. In developing countries, or those affected by war

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and civil unrest, the funding to pay for vaccinations and the health infrastructure required to

deliver a programme may not be available. Even in countries such as the UK where there is

a well resourced childhood vaccination programme, not all children are able to benefit. A

very small number are unable to have vaccinations because of particular medical

conditions. A far greater number of children are not immunised because their parents do

not take up the vaccinations offered.

For most vaccine preventable disease, the number of children who are unvaccinated is

small enough to allow herd immunity. This means that the unvaccinated children are

protected because enough other children have been vaccinated to prevent the infection

circulating through the community. However, in the case of the MMR vaccine in the UK, the

uptake is low enough in some places, including Shetland, to allow measles to circulate,

potentially causing outbreaks of illness.

One of the reasons why parents do not vaccinate their children is because they are not

convinced by the evidence given by healthcare professionals and scientists for the need for

vaccination. Of course people have a choice: but the scientific and health communities

have a responsibility to ensure that the information we give out to people is accessible,

consistent and understandable so that people can make an informed choice regarding

vaccinations, as with other health protection and health improvement interventions.

A Model of Health Improvement

In thinking about health improvement

actions and programmes, it is helpful

to have a structure in place to plan

activity. There are a number of

models of health improvement: the

one on the left was developed by A.

Beattie in 1991.7

This model shows that health

improvement actions can be at an

individual level, or population level, or

somewhere in between. They can

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Health promotion in schools

also be authoritative (telling people what to do) or negotiated (enabling people or

populations to change), or again somewhere in between.

Different health improvement activities can be plotted somewhere on this grid: so legislation

such as the ban on smoking in public places, seatbelt laws, age restrictions on the

purchase of alcohol and tobacco is at a population level and is authoritative. Smoking

cessation and weight management services are generally at an individual, or small group,

level and tend to be negotiated.

Most health improvement programmes need a range of activities spread across the grid to

be effective. So if we have public information campaigns to tell people to stop smoking, we

also need to put in place smoking cessation services to help them.

The range of interventions that we employ for particular health issues will vary. In general

the provision of information and education, at individual (e.g. advice from the GP), small

group (e.g. school) and population (e.g. national campaigns) levels is the basis of many

programmes. If we are looking at individual behaviours such as smoking, drinking and

physical activity then individual „negotiated‟ activities will be useful as long as people take

them up. If we are looking at protecting individuals or groups, then legislation is useful;

legislation can happen when we have an agreement in society to oblige people to comply

Alcohol and tobacco sales

Ban on smoking in public places

Midwife advising a pregnant woman to stop smoking

Facilitated weight management programme

Community group identifying a health need developing own solutions

Support group for help people with alcohol problems

Article in local press about flu vaccination

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and to police that compliance, which is as much an individual as a group responsibility.

Legislation is often about protecting children (e.g. minimum age laws) or other members of

the population whose health could be affected (ban on smoking in public places; drink

driving laws).

It is important to recognise that just telling people to do something or not do something

does not necessarily change an individual‟s behaviour. Wearing seatbelts is an example.

Whilst legislating for passengers (especially children) can be seen as protecting the people

who are not in control of the car, it could be argued that the driver should be able to make

their own choice, given balanced information. But before legislation, compliance with

public information and advice was poor. In the UK a law was introduced in 1983 requiring

drivers to wear seatbelts. This must have been seen by the population as something so

necessary, that people should not have a choice, although it took more than ten years to

get it through Parliament. By this stage, the population was generally accepting of the

rationale for the law, and as people are generally law abiding, and action was taken against

those who did not comply, then they did change behaviour. 8 Now in 2012, seatbelt

wearing is taken for granted by nearly all the population: though we still see public safety

advertisements reminding people.

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We do also use the evidence that says that a GP, or other doctor, spending a few minutes

discussing smoking with a patient or asking them about drinking, can be the catalyst that

someone needs to make them change behaviour. It does not seem to happen frequently,

but it is such a relatively low cost action that only a few people have to change behaviour to

make it cost effective.9 And although that particular conversation may not be the one that

persuades someone to change behaviour, it may help them start to think about it and

eventually they will decide themselves to make the change; especially if they are hearing

the same message in other settings. When smoking cessation services were first brought in

across the UK in the late 1990s, this „brief intervention‟ was the first element of a tiered

approach to supporting people to quit. More recently in Scotland we have introduced the

Alcohol Brief Intervention (ABI) which is a similar idea, that by asking a patient about

drinking and giving some brief advice, a proportion of people who have harmful drinking

patterns will modify their drinking without any further help. 10

But what we often find is that some groups of people find it much easier to change

behaviour than others. The people who can find it most difficult are those who are more

disadvantaged, vulnerable, socially excluded, or have multiple health issues for example.

And there is a problem in that when health improvement interventions are implemented on

a population wide basis, they are most effective in changing behaviour in the groups that

find it easiest to change and less effective in the more vulnerable groups, which means that

we effectively leave behind people who are more disadvantaged and the inequalities gap

increases. This is discussed further in the chapter on Poverty & Inequalities. These

limitations with traditional programmes have led to a more targeted approach in many areas

of health improvement, such as using social marketing techniques for campaigns.

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Social marketing is a method of applying the science of marketing to social policy and behaviour change in the context of health improvement. In a book on social marketing, subtitled „Why should the devil have all the best tunes?‟, Gerard Hastings argues that the techniques used by big companies to get us to eat big brand beef burgers and smoke particular types of cigarettes can also be used to encourage people to eat healthily, preserve their lungs and walk to work.11 But to do this we need to be cleverer about understanding our target audiences. Social marketing uses techniques such as branding and „segmentation‟, therefore understanding the very different reasons that people have for (e.g.) drinking alcohol, and the very different ways that different groups of people use alcohol will help us to design interventions which are far more likely to have an impact on them, because they are far more likely to be relevant.

Shetland Public Health Annual Report 201012

There is also the balance between targeting interventions and yet not stigmatising people.

So for example, in Shetland we have a sexual health clinic that is open to anyone, and is

promoted as such. The advertising for the clinic has to be targeted to ensure that all the

potentially more vulnerable groups see the clinic as being for them (for example young

people and older people, people who are lesbian, gay, bisexual and transgendered).

Furthermore, where people find it more difficult to make behaviour change to improve

health, then health improvement interventions have to make it easier for people to make the

changes.

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What influences behaviour?

In previous Public Health Annual Reports we have looked at what motivates people to

change behaviour. In 2010, we wrote about risk taking, and how people decide what action

to take based on their perception of risk:

Threats that are unfamiliar, exotic, involuntary and „man made‟ are often seen as more of a

health risk than those that are familiar, domestic, voluntary and „natural‟. So people often

worry less about the potential health effect of, for example, smoking and excess alcohol

(familiar, domestic and a voluntary element) than the potential health effects of terrorism or

nuclear accident (unfamiliar, involuntary and man made) or bird flu (unfamiliar, exotic and

involuntary).13

In last year‟s Annual Report we looked at different approaches to influencing behaviour

including the „nudge‟ approach as favoured by the UK Government:

The government cannot force people to live healthy lives. People can be helped and

encouraged to make healthier choices. Local communities working together, and with a

good understanding of human behaviour, will achieve more than extra laws and lectures

from the government.14

In 2011, the House of Lords Science and Technology Committee published a report on

behaviour change.15 This describes how some choices are consciously planned or

deliberative, and some are unconscious or non-deliberative. The report uses the analogy of

buying and driving a car: buying a new car will usually be made only after much conscious

deliberation (along with unconscious motivations), but when a car is being driven down a

very familiar route the driver will be acting automatically, ie not really having to think about

where they are going. The report states:

Both deliberative and non-deliberative choices and actions can be affected by social factors

(such as personal interaction and interaction within, and between, groups) and the large-

scale social context (such as state of the economy). Behaviour is also influenced by the

physical environment in which it takes place. The ready availability of cheap and unhealthy

food, for example, makes it more likely that people will consume it. Similarly, if there are

very busy roads and no cycling lanes, people are less likely to travel by bike.

So, for example, the smoking ban has made it easier for people who want to stop smoking

to avoid cigarettes when they are on a night out; creating safe footpaths and green spaces

makes it easier for people to walk and exercise outside; reducing the price of fruit and

vegetables would make it easier for people to choose these over other foods. Whilst this

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has been done using legislation in many cases, there is still a long way to go in changing

environments to make the healthier choice the easier choice.

The House of Lords report went on to discuss what are the gaps in our knowledge about

behaviour change:

....lack of understanding about aspects of the automatic system, particularly in relation to

how emotional processes regulate everyday behaviour; a lack of comparative research into

the limits to the transferability of behaviour change interventions across cultural differences;

uncertainty about how genes interact with environmental and social factors to cause

behaviour; and, a lack of understanding about the effect of social dynamics on behaviour.....

So there is clearly more that we need to understand about what motivates and supports

people to change behaviour; and especially which of these factors we can influence, and

how. However, there is a lot that we do already know, and the following sections look at

how far we have come in changing behaviour and improving health across our three priority

areas: smoking; alcohol and obesity.

Smoking in public places: legislation and changing attitudes

The history of smoking, and tobacco control, can be used as an example of how there had

to be changes to a number of different factors in order to improve health (in this case by

reducing smoking behaviour). Firstly there had to be an acknowledgement that smoking

had an adverse effect on health. This was suggested as far back as 1604, but the large

scale studies that showed a clear link between smoking and ill health were conducted in the

1950s. Up until that point smoking was seen as the „norm‟ with two thirds of men and

increasing numbers of women smoking tobacco. Smoking was promoted in the armed

forces during the two world wars; cigarettes were included in soldiers‟ rations and millions of

free cigarettes distributed by tobacco companies. In America,

tobacco was designated as a protected crop and certain brands

used the fact that doctors smoked them as an endorsement for

that brand. Even when the scientific evidence was available, it

took years for Governments to take action which could affect their

revenue from tobacco taxation, and which put them up against the

powerful tobacco industry.

In 1999, David Pollock published a book called Denial & Delay,

subtitled The Political History of Smoking and Health, 1951-1964:

Scientists, Government and Industry as seen in the papers at the Public Records Office.16

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This book described the earliest steps in trying to convince government and society that

tobacco was damaging to health. Pollock describes how, year after year, expert statements

from advisory groups and the Medical Research Council were watered down and ignored.

Anecdotally, Iain Macleod, the Chief Medical Officer at the time, chain-smoked while he

made the first Ministry of Health announcement on the subject!

The annual reports of the Medical Officer for Health for Shetland in the 1950s illustrate quite

clearly the uphill battle he had with trying to persuade the population, and the local

authority, that smoking should not be allowed in public places.

Anti-tobacco campaigners found themselves constantly up against the commercial power of

the huge tobacco companies and frequently up against a lack of political will to introduce

truly effective public health policy backed by resources. This began to change in 1998 with

the publication in the UK of the White Paper Smoking Kills. 17 This document set out the

first UK wide action plan for Tobacco Control and included a number of proposals involving

topics such as tobacco advertising, health promotion campaigns, taxation and smoking

cessation. However, the effects of the new policy took time to change smoking behaviour.

In the early 2000s, the Director of Public Health Annual Reports still reflected tackling

smoking as a seemingly impossible task:

1956: “Efforts to persuade the young to remain non-smokers are unlikely to be successful unless we are prepared to show moderation in our own smoking habits. Could not a start be made locally by the public agreeing to give up smoking in buses, cinemas, restaurants and food shops? “

1957 “In time the public will object to seeing a layer of smoke exhaled from the lungs of others settling over the table in a restaurant or over the food in a Baker‟s shop.”

1958 “The climate of opinion at present is such that I think we must wait and hope that in a few years time the public will start listening to the small voices of the few who are trying to call attention to this health hazard.”

2001 “after almost 30 years of public health campaigns, smoking still stands as an apparently intractable health problem”

2002. “....offering smoking cessation programmes has only limited success. Having smoke free environments, encouraging non-smoking role models and making it easier not to smoke through non-smoking policies are more likely to be successful in the long term.”

2003 “The aim in this area of public health policy must be to create a society in which non-smoking is the norm, with smoking areas designated where necessary and convenient, rather than the reverse…….smoking in public places still remains the norm despite the fact that less than one third of British adults are smokers.”

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Then in 2004, a Scottish Action Plan, A Breath of Fresh Air, was published. 18

And in 2006, a ban on smoking in workplaces and indoor public places became legislation,

along with some optimism:

That was six years ago. Where are we now in 2012?

The chapter on Smoking discusses progress against our local

ambitions to become „Smoke free‟. The smoking ban has been well

embedded, and there has been further legislation such as raising the

legal age for purchasing tobacco to 18. We continue to educate and

inform at both the individual and population level. Smoking cessation

services are prioritised in Shetland, with significant local investment.

They continue to be well used, but there is an increasing focus on

engaging with the harder to reach and more disadvantaged groups

who find it harder to give up smoking. We have also looked at how

we can increase uptake of services using incentives by introducing a scheme to „reward‟

people with vouchers for the local leisure centres when they first quit smoking, and if they

continue to stay off cigarettes.

Shetland is not yet smoke free; though we appear to again have reached a plateau. The

Scottish Health Survey in 2011 showed that 19% of people in Shetland were smokers,

which is the second lowest in Scotland, but still too high.19 We are aiming for 5% or less,

but we will not know until 2014 when the next figures from the Scottish Health Survey are

published, if recent action has had an impact. In Shetland the number of people aged

under 75 dying prematurely from heart disease has halved over the last 10 years. This can

be attributed at least in part to the reduction in smoking. We do know that despite

education and information, legislation, and significant changes in society‟s attitude towards

smoking, young people are still taking up smoking. Perhaps the less socially acceptable

smoking becomes, the more desirable it is to a rebellious teenager.

2006 ...we have seen the introduction of one of the most significant pieces of legislation aimed at protecting public health. The Scottish „Smoking Ban‟, part of the Smoking, Health and Social Care (Scotland) Act, came into force on March 26th 2006. It is designed to protect the public from environmental tobacco smoke by making smoking in enclosed public places and workplaces illegal. Combine this with a record number of smokers accessing local smoking cessation services: are we on the way to a „Smoke-free Shetland‟?

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National policy and local action have not to date focused on the „population / negotiation‟

quarter of Beattie‟s model. This is where our focus now needs to be (whilst maintaining the

other activities) to achieve a further reduction in the number of people who smoke. The

next chapter describes different ways of working, that are not just community based, but

community led and certainly at the negotiated end of the spectrum.

Alcohol: changing the culture

Alcohol has been a part of our culture, in Shetland as elsewhere in the UK and most of the

rest of the world, for centuries – drinking alcohol for „recreation‟ has been going on for 7000

years.20 Alcohol is a recognised and welcomed part of many social activities – from toasts

at a wedding or „wetting the baby‟s head‟, to the traditional New Year dram and sharing a

bottle of wine with friends in a restaurant for your birthday. In some circumstances alcohol

may be actively beneficial: there is some evidence to suggest that light drinking may confer

some health benefits on some people, for instance a reduction in the risk of coronary heart

disease in middle aged and older men in populations with high risks of heart disease (one

drink every second day gives almost all the benefit there is, and over two drinks per day

increases the risks of heart disease).21 This is a key way in which alcohol differs from

tobacco. Any level of smoking carries a risk; but alcohol can be enjoyed in moderation with

no adverse health effects. Although, overall in a population the protective effects are

probably cancelled out by the increases in deaths from other causes related to alcohol

misuse.

The problems associated with alcohol have also been recognised for many years. During

the 8th century, this was written to the Bishop of Canterbury:

“In your diosceses, the vice of drunkness is too frequent. This is an evil particular to Pagans

and our race”

As early as 616 AD there were laws about the opening hours of ale houses; in 1552 the

Alehouse Act was introduced in England to control drunken and rowdy behaviour; and

legislation continued to be used through the 15th and 16th centuries. In the past there have

been episodes where alcohol related problems were seen as a serious national threat

including during the 18th century „gin epidemic‟ and during the first world war. During these

times there were more punitive measures (in Shetland in 1919, the majority of licensed

premises were closed as the result of a local vote by the public – although people did

20

manage to get around the legislation and continue drinking22) but in general the UK has

adopted a low key „harm minimisation‟ approach. Policies of prohibition have not been

shown to work in any country in the world where alcohol has historically been part of the

culture.

Like tobacco, national and local programmes to tackle alcohol problems include a range of

activities that fit into different parts of Beattie‟s model. Informing and education has been a

key element for many years, with a particular focus on children and teenagers. As above,

licensing laws have been in place for a long time and clearly sit at the „authoritative /

population‟ quarter of the model. They are designed to protect both the more vulnerable

population, i.e. children, largely with age restrictions; and also to protect individuals who

choose to drink alcohol but in a way that puts themselves or others at risk of harm. So there

are limits on when and where alcohol can be bought, and taxation which increases the

price. National policy is also to bring in minimal pricing. Similar to tobacco there are

services to help people cut down or stop drinking alcohol. However, interventions of the

individual / negotiated type can be complex, with issues such as mental health problems co-

existing with the alcohol problem. However, as we can see with the comments from the

Public Health Annual Reports relating to tobacco, there is a need for a change in attitude

and culture, before other interventions can be accepted, ideally welcomed, by the

community.

In 1979 there was a symposium held in Shetland on „alcohol related problems in Shetland‟

which highlighted the issue of alcohol misuse in Shetland and ways to tackle it, and then in

the 1980s there were a number of academic papers published on the alcohol culture in

Shetland by a group of Scandinavian authors.23 However, in the 2006 Public Health

Annual Report we wrote:

We can be pessimistic and ask why things haven‟t changed even since 1979 when we were

clearly recognising the problem. Of course some things have changed: we have a much

more developed range of services for people seeking help in dealing with their drinking

problems – the formation of local Alcoholics Anonymous groups (AA), the development of

the Shetland Alcohol Support Services, a specialist nurse and a dual diagnosis team

(dealing with people with substance misuse and mental health problems). And the culture

has changed to some extent – within national policy – we are now talking more freely about

21

the issues of alcohol misuse, and some patterns of behaviour have changed significantly:

for instance drink driving, and education in schools. 24

Back in 2006 we were also looking for new ways to tackle the alcohol problem, and came

across a new approach from Canada. We shared our enthusiasm for this new approach in

the Annual Report:

But none of this [programmes in other countries] looked particularly successful until we

found the experience of Quebec province in Canada, where over the last 15 years a

concerted programme – Educ‟alcool , has brought about some impressive changes in the

way that alcohol is used and misused – it has literally changed the culture of drinking and

the patterns of alcohol consumption.

At that time, we were used Drink Well as the slogan but this is now the familiar Drink Better.

The Drink Better programme aims to change attitude: it is about information and education,

but also about community and understanding behaviour and seeking relatively subtle

changes for most of the population. It is now six years since we discovered this approach:

so has Drink Better been successful?

The honest answer is –we don’t know yet. Changing culture and attitude takes a long

time, probably generations. In Canada, the Educ‟alcool programme showed impressive

changes after 15 years.

22

We do now have a baseline of what people in Shetland‟s attitudes are to drinking. In 2011

we carried out the Drink Better Survey and found that 60% of the 1200 respondents said

they had previously read or heard about the Drink Better campaign, or seen the logo. 82%

thought that people in Shetland drink too much. The rating of the most challenging aspects

of changing a person‟s drinking habits within the Shetland community differed according to

age group. 13-25 year olds said the reasons for drinking were firstly „Boredom‟, secondly

„Peer Pressure‟ and thirdly „Culture‟. And the 25 + age groups said it was firstly „Culture‟,

secondly „Attitudes‟ and thirdly „Peer Pressure‟.

The top three priority areas which respondents felt Drink Better should focus on were:

“Awareness raising with young people on the effects of alcohol on the body and

brain development.”

“Educate the public about the risks of excessive drinking.”

“Educate adults about their drinking behaviour to become better role models.”

The Drink Better Survey Summary will be found on the NHS Shetland website soon.

Obesity: tackling poor diets and lack of physical activity

In some ways, this is the hardest health issue to tackle out of „the big three‟. Everyone has

to eat, so the messages we give to people become more complex. We can be clear that,

from a health point of view, smoking is unnecessary and very harmful, so we can advise

people not to smoke at all (although of course actually giving up smoking is not easy, but

Drink Better is Shetland's long-term vision for a future where alcohol is consumed for its taste and quality, not for the sake of getting drunk. Rather than focussing on the negative aspects of alcohol consumption, Drink Better aims to embrace the positive culture of drinking; we want a culture where people 'drink better'.

The key messages are:

Drink a bit less on each occasion

Sometimes don't drink at all

Drink better quality products

Drink in the right context - not as the main activity

Drink for the right reasons, not to drown your sorrows

Respect those who choose not to drink at all

23

the message is clear). Alcohol is probably a bit harder to tackle, because as discussed

above, small amounts do no harm, and may in some cases be beneficial (and again, for

someone who has an alcohol problem cutting down or reducing alcohol is not easy).

But when considering diet and physical activity the message is more complicated; we are

not talking about just one behaviour as with smoking (i.e. don‟t smoke); the messages

include eat more of some foods, less of other foods and take more exercise. In some ways

it should seem easier to be able to change eating behaviours compared to smoking and

alcohol use; after all unhealthy food is not considered addictive in the same way as tobacco

or alcohol, even if some people find it incredibly difficult to change their diet. But there are

many factors that do make this a very difficult issue to tackle as discussed below.

We don‟t have a really good way of defining a „normal‟ or „healthy‟ weight. We use

„body mass index‟ or BMI which takes into account height and weight, and for most

people this does give a good indication of being over or underweight. But it does not

take into account how much of someone‟s body is made up of fat and how much is

muscle, and how big or small their „frame‟ is. Measuring BMI in children can be

particularly difficult because of the way they grow and the way that puberty affects

them. The charts we use to assess children take age into account, but children do

not all have „growth spurts‟ or reach puberty at the same age; very low BMI can

also reflect a small frame or low muscle mass. 25 For adults, we can use other

measures such as waist circumference which gives an idea of how fat is distributed

in the body, and we know that this can affect the risk of developing specific

conditions such as heart disease.

Although the current concern is with overweight and obesity, being underweight can

be just as harmful. In some parts of the world low weight and malnourishment are

major health issues; and within our communities there are people who may be

underweight due to illness, neglect or mental health problems. So although the

majority of people in our communities need to be encouraged to either maintain their

current healthy weight or lose weight, there are a minority who may need to gain

weight. This makes it more difficult to give out population wide messages.

Furthermore, being over or under weight is not the same as being „malnourished‟.

Depending on their diet, there are overweight people who do not have enough

essential nutrients such as iron, vitamin C and protein. Equally there are people

24

considered to be underweight who have a very balanced diet, containing all the

essential nutrients.

Different communities, groups of people and individuals have very different attitudes

and beliefs about weight and body shape. In some cultures being overweight is

considered desirable; in others people who are obese are stigmatised. Some

people, young girls and women in particular (but not exclusively), aspire to be like

the very skinny models, actresses and celebrities they see in the media. Other

people celebrate having a larger figure: „big is beautiful‟ and would argue that you

can be healthy and fat. However, whatever your attitude and beliefs; the fact is that

carrying too much weight will increase risk of ill health, and the more overweight you

are the more the risk. And being too underweight will also increase the risk of ill

health.

There is also an argument that constantly „battling‟ with your weight and worrying

about everything you eat, can cause psychological distress and more ill health than

staying overweight. This is why preventing overweight and obesity in the first place

is so important; and making sure people are getting the right messages and have

the support they need when they do want to lose weight. And, even if someone is

overweight, if they have a nutritionally balanced diet and do plenty of physical

activity, then they probably are „healthier‟ than someone who looks slim, but lives

on cigarettes and diet cola and never does any exercise.

The science (and the public health message) is clear: overweight and obesity are

caused by too many calories (or energy) going into the body, and not enough being

burnt off. Although it is not quite as simple as saying eat less – because what we eat

is as important as how much we eat. A can of sugary fizzy drink and a bag of crisps

may have fewer calories than a chicken sandwich and banana, but which should you

choose for lunch? And these messages are lost amongst all the information that

people are bombarded with everyday. There is a huge industry around diet, nutrition

and weight management, which gives out subtle and confusing messages to the

general public.

Finally, probably the hardest issue to tackle is the fact that we now live in a society

that is designed to make us put on weight – we call this the obesogenic

environment. Evolution has meant that humans are designed to eat well when food

is available, and to conserve energy whenever possible, in case the food runs out.26

25

This may have been fine for our cavemen ancestors, but in our society now we have

huge amounts of cheap „high density‟ (lots of calories, but doesn‟t really fill you up)

food available, which we eat. And we have so many ways now to avoid expending

our energy in all aspects of our lives: lifts and escalators; automatic washing

machines and tumble dryers; bread makers; remote controls; cordless telephones;

sit-on lawnmowers; on-line shopping. Not only have we reduced the energy we

have to expend in carrying out day to day chores; but information technology has

increased the amount of time many of us sit at desks and work from home; and

leisure time is becoming dominated with sedentary pursuits.

With all this going on, how can we possibly achieve any success using traditional public

health interventions? We do have to continue with the „basics‟: information and simple

messages for the public; education in schools and some legislation (such as nutritional

content of school meals), aimed at preventing weight problems. We also need to continue

services for people who have weight problems. But with this level of complexity and

environmental and cultural factors, we have to look at the bigger picture and to focus our

activity in the „population / negotiation‟ quarter of Beattie‟s model. We need to enable

populations and communities to make shifts in culture and attitudes and to reverse the

trend towards an obesogenic environment. There has been some work on the relationship

between the obesogenic environment and environmental sustainability: basically if there are

fewer natural resources such as oil and food available, then the environment would become

less obesogenic. This means that environmental sustainability should be a key focus of

public health action, not just for its own sake, but to improve health.27

Conclusion: how far have we come?

We have had huge successes in many areas of improving health, from provision of clean

water, to safe and effective vaccination programmes and reduction in tobacco use. These

have all required years of work to understand the science behind the health problem and

how it can be tackled; followed by gradual shifts in society‟s understanding, attitudes and

beliefs which can then allow populations and individuals to make changes. These might be

Governments changing laws or national policy, or individuals and groups changing their

own behaviour.

26

However, even where we have made great progress there is still more that we can do:

achieving smoke free communities; ensuring clean water for all parts of the world;

increasing vaccination uptake amongst all populations. And then there are the health

issues where we have not made so much progress: particularly alcohol and obesity. Much

of the work has been done to understand the science behind the issues, and what the

solutions might be, but we have only got part way in being able to implement these.

We have the building blocks in place for all our health improvement activity: information;

education; work with children and young people; services to help people who smoke or who

have a weight or alcohol problem. We have good evidence of what works in most of these

areas, and we are constantly aiming to improve both how we deliver these services and

how we share the responsibility for them with our colleagues in the local authority, the

voluntary sector, workplaces and local communities. However, there is a danger if we carry

on in the same way that we are simply „re-arranging the deckchairs‟ or making small

changes at a very slow pace, rather than really making a difference to the health of the

Shetland population, and sustaining improvements in health. This requires changes in

attitudes, beliefs, culture and behaviour and embedding these changes in our communities.

How do we achieve this? We need to build on the success we have achieved so far

where we know what works, but also need to take a different approach to improving

public health if we are to make significant and sustainable change.

27

Asset-based approaches – not the ‘nanny state’

We understand that „poor‟ or „good‟ states of health are not just about „lifestyle choices‟ and

individual risk factors. This is where it helps to think more holistically about people and the

personal and social context in which people live, which frames the choices they make about

lifestyle and risk factors.

So we might drink too much to forget about past or present traumas, or turn to „comfort

eating‟ when we‟re unhappy or bored, or smoke to relieve the stress of a difficult situation,

and these ways of coping are harmful in themselves. Being healthy is about finding ways of

coping that are less harmful, even healthy in their own right; that actually deal with problems

rather than hiding from them, or getting immediate relief to feel better in the short term but

not really sorting things out.

In last year‟s Annual Report we talked about new definitions of health that are about

wellbeing, and the ability to adapt and self manage in the face of social, physical and

emotional challenges.

Wellbeing:

“what it takes to make life worth living”28

“a sea change in the way we view health – from illness to wellness” 29

In child development we now talk about the range of things that give children the best start

in life through the policy of Getting It Right For Every Child30. These include elements of

being healthy and active, achieving, included, responsible and respected, safe and

nurtured.

As we say elsewhere in this report, current national policy on public health increasingly

focuses on early intervention, and we want to develop that approach to one of prevention.

28

The challenge then becomes one of what works as intervention – how do we help people

towards wellness and health when we recognise that the world is a complex place with

many conflicting influences?

So we try and address “the entire biological, material, social and cultural dimensions of the

human, living and physical world” in models such as ecological public health31.

We plan to take public health action at all the levels of intervention / domains we have

described, including at times, the use of legislation. But we know that people value their

personal freedoms - their autonomy, and this argument is used to support the individual‟s

right to smoke, or drink too much, or eat what they choose. The society we live in generally

allows adults capable of making their own decisions to make choices for the better or

worse, but gives particular protection to those we consider vulnerable such as children, or

adults in need of care and protection. And again, we‟ve already talked about some of this

protection on public health themes.

So how do we get the right balance between people making their own choices, however

personally damaging, and taking action to prevent harm?

29

One helpful approach is to understand coherence and resilience.

The Equally Well Coherence Triangle32: this diagram illustrates a „sense of coherence‟, in

which the external environment is perceived as comprehensible, manageable and

worthwhile. Without this sense of coherence, people are more likely to be subject to chronic

stress and poor health.

Resilience can be defined as the confidence and resources to deal with the stimuli of

everyday living. For some people, indeed at some time in most people‟s lives, everyday

living can be full of adversity and very difficult, and we vary in how well equipped we are to

deal with what comes our way. Some research tells us that the ability to make sense of the

external environment is achieved most readily by consistent parenting experienced early in

life 33. As individuals grow and learn, they develop supportive social networks through

school and then work, and acquire a set of resources which allow them to make sense of

the stresses they encounter in daily living, helping them to manage their life effectively. If

this is disrupted or people‟s experiences are poor or damaging, it increases vulnerability to

physical as well as mental ill health.

30

Social and economic disruption leaves people less resilient psychologically to face the

challenges of modern life. This makes some intuitive sense – life feels easier to deal with

when we have stability in our lives and enough money to get by.

Understanding resilience is about understanding the value of the „locus of control‟ – that

sense of coherence, and there are some modern theories about how this plays out in the

physiological mechanisms that deal with stress. In simple terms, if we feel in control of the

world around us, we appear to be better equipped to deal with the challenges it brings, at a

basic biological level as well as emotionally and socially.

Asset-based approaches are based on the evidence that we can build people‟s capacity

and positive capability for resilience and coherence - to solve the problems that they identify

in their own lives, both at an individual level – what it will take for me to deal with my

addiction: to find the motivation and support I need to stop smoking or drink less; and at a

community level – how do we help each other, contribute to making our surroundings as we

want them to be, have control over our daily lives and how to change them for the better.

So this starts to provide us with some answers as to how we can intervene to improve

health (in its widest sense) without becoming the „nanny state‟.

To do things differently, and to do different things.

We set ourselves a challenge in last year‟s Public Health Annual Report34 where we briefly

described what we mean by asset based approaches and co-production, and asked

ourselves how much of this was within our grasp…. where we also talked about a new

wave of public health thinking35 emerging that changes how we understand the world, how

we solve problems and move forward. If we are to do this in a more coherent way it will

require a real shift in mindset, a cultural change.

The characteristics of a resilient system include the ability to change, re-organise and learn. “Resilience shifts attention from purely growth and efficiency to recovery and flexibility”.

Health Protection Stocktake draft report 2011

31

It needs stories and connections to people‟s real lives to show how different things should /

could be: “stories of real people in real places making real change”.

So perhaps we can offer some of those stories to illustrate the direction we want to go in

and how to get there.

For instance increasingly we see mental health defined as promoting the capacity to cope

and recover36 and many of the stories told as part of Recovery are full of insight:

Remember, if you want to ‘help’ me, you are implying that I can’t cope on my own. I

would rather you believed implicitly, that I can cope even if it may be a struggle. If

you want to ‘help’ me you can go away. If you are willing to come and join me in

my struggle, so that I can discover a way of dealing with it for myself, I’ll be happy

to have you stand beside me.

Roger Casemore (2007)

Recovery is a concept applied also in dealing with substance misuse.

32

There are a number of different models used in addiction work, including the addiction

model where some people are seen to have an „inbuilt‟, even medical (physiological)

propensity to become addicts; the characterological model, which consider early trauma

and personality disorders to be the main factors; the psychological approach, where

behaviours are learned and can be "unlearned"; and perhaps more in line with our public

health view of the world, the bio-social model that sees drug and alcohol misuse as the

result of a complex interaction between the drug, social situation and psychological health

of the individual, linked to the "Drug, set and setting" approach37.

Despite the many approaches, and conflicting evidence about which is more effective,

consistent elements in addiction recovery appear to be: peer support, a focus on an

individual's dignity, and building up a person's self-esteem and pride.

So recovery is not just about abstinence, it's about how someone sees themselves and how

they build their capacity to change.

“nobody else can recover me I have to do that myself”

“Learning to walk away from the top of a slippery slope is a hard lesson to learn yet

once you have learned it recovery becomes very rewarding”

“There’s always a way out. Before I got into recovery I was in a dark tunnel with no

way out then I saw the light at the end. A bit of positivity to aim for.”

Quotes from the CADSS Recovery Exhibition, Isleburgh 2012

Adding a social dimension, and thinking about the value of community, illustrates some

other „success features‟ that we talked about earlier.

Social Capital: “the ability of people to work together for common purposes”.

Fukuyama

or “the web of cooperative relationships between [people] that resolve problems through collective action”.

Brehm & Rahn

33

Combining the personal and community approaches, for instance in understanding the

strength of therapeutic relationships in building community responses to local problems, has

given some exciting and powerful solutions.

The Alaska experience: The “Nuka38 System of Care” is a healthcare organization in Alaska set up to meet the health needs of Native Alaskans – a group with high levels of drug and alcohol dependency, high rates of depression and suicide, domestic and other abuse compared to the US average. Yet over 15 years it has achieved remarkable improvements in population health at significantly lower cost for similar populations elsewhere. It is based on a simple truth that “good quality relationships equal healthy people”. Its principles include:

Emphasis on wellness of the whole person, family and community including physical, mental, emotional and spiritual wellness.

Shared responsibilities - working together with the customer-owner as an active partner, and the interests of the customer-owner driving the system to determine „what we do and how we do it‟.

A more local example is the „LIFE‟ type model of family-centred solutions39

currently

being developed in England, which is a programme working alongside families struggling to

cope with multiple difficulties, committed to change, building their skills, strengths and

assets to build lives they want to lead. A number of these examples illustrate some of our

approaches to tackling inequalities, because these are the entrenched problems that

haven‟t been solved by the „old‟ or current mainstream ways of working.

There are some interesting challenges locally that we might apply new thinking to. Where

our current services are not sustainable, can we look at asset-based approaches to find

different solutions to our current problems?

Where are our local resources, and how do we make best use of them as assets? Can we

think differently about the public sector in Shetland, and how we involve communities in

changing the services we provide - not just the decision-making, but in the action we take?

When we talked with young people about poverty in Shetland, they described using budget

cuts to catalyse innovation, and using people to take ideas forward.

What if we look at providing some of our services in different ways - alternative models of

delivery. There are for instance, examples of social enterprise organisations working in

health and care, in the leisure industry, in youth services.

34

Or increasingly, a range of organisations are looking at their corporate social responsibility

through furthering health or care outcomes – this means their responsibilities for the

communities they serve and how they might improve health and wellbeing through their

business.

So for instance, an organisation like the Recreational Trust might not have the same

responsibilities as Public Sector organisations on diversity and equality because of its

charitable status, but it might want to exercise its corporate social responsibility by positively

encouraging people on low income or with disabilities to use its facilities through discounts

or active recruitment into targeted activities. This sort of thinking is increasingly considered

to be a mark of a 'new horizons' enterprise that sees potential 'profit' in community as well

as economic terms (though they still have legal duties).

This is particularly relevant to our situation in Shetland at present, given the level of public

sector cuts and the savings we have to make from services. Despite the urgency of our

current situation, the challenge is to think more strategically about our approach and to find

different ways of doing things that will cost us less in the long run as well as balancing the

books this year. We have many assets in Shetland, not just in the financial sense of the

word, but in facilities and infrastructure, in the strength of our local communities, in the

willingness of Shetland folk to be entrepreneurial and opportunistic. Using the same

example as before, we have more swimming pools per head of population than any other

A social enterprise is a business that trades for a social and/or environmental purpose. It will have a clear sense of its „social mission‟: which means it will know what difference it is trying to make, who it aims to help, and how it plans to do it. It will bring in most or all of its income through selling goods or services. And it will also have clear rules about what it does with its profits, reinvesting these to further the „social mission‟. Social Enterprise UK.

“The danger is that public services will retrench into „sticking plaster‟ solutions, patching up problems when they occur rather than tackling them at source and that people themselves will lose confidence and hope and a sense of powerlessness will prevail. But it doesn‟t have to be that way. The fact is that challenges often prompt us to think afresh, to regroup and embark on a new – and often better – course of action.” Joining the Dots, Professor Susan Deacon

35

Local Authority in the UK. Perhaps the challenge is how to get more people through the

doors of our leisure centres, more often; to use them to get our levels of physical activity up

to those we know we need to make a difference to our health; and to reap the benefits of

our assets rather than thinking of them as a liability. The later chapter on obesity tells us

that less than 40% of Scottish adults take the recommended amount of exercise. If this

applies in Shetland then we should be aiming to double the number of people coming

through the doors of our leisure centres. This would be a real example of partnership and of

an asset-based approach to health improvement.

The other value of these approaches is that they change our thinking about services and

the public sector and our increasing understanding that the status quo is not sustainable.

36

Ageing population

Despite many older people being fitter than their grandchildren, the fact that there are more

people over the age of 75 in the population compared with 20 years ago is placing

increased demand on many services such as renal replacement therapy, dementia care,

dental care, prescription drugs, joint replacements, cataract operations etc. Current

estimates suggest this trend requires a 1.1% increase in the NHS budget per year to be

met.

Ageing can vary hugely in its pace depending on a wide range of factors. Some of the best

evidence on how to slow down the process suggests you need not to smoke, eat a diet rich

in vegetables and whole grains and low in red meat, exercise 3-5 hours a week and keep

your waistline. Having all four elements in your life will increase your healthy life expectancy

by 12 years compared with having none of them.

Given that fewer than 10% of the population do this currently, there is a question mark over

the estimated increase in demand that an ageing population may cause. If the majority of

the population adopted these lifestyle changes, there would be a systemic change in

demand for healthcare. The problem is that current efforts to reduce the adverse

consequences of ageing have yet to make such a systemic impact. 40

Increases in obesity lead to increases in diabetes and heart disease, higher risk of

complications in surgery and pregnancy, and a requirement for larger trolleys, beds, and

hoists to help obese patients move around hospitals.

The costs of adaptations to an obese patient‟s house will cost in the region of

£23,000, a cost that is often met by the local authority but is still met from the public

purse.

Stair lift £8,000

Level access shower £4-5000

Widening external door £1000

Widening internal doors £2500

Bariatric bed £4000

Bariatric chair £4-5000

37

The International Futures Forum identifies considerable potential in the prevention agenda

for reducing the burden of illness in the population and thus the demand on the NHS, but

notes:

Jimmy Stout in a recent article in Shetland Life41

said “perhaps our solution [to the fact that

our way of life in Shetland is at present unsustainable] could better lie in collective

responsibility......communities must find their own solutions at every level....this better way

forward calls for coordinated community effort...”

So perhaps this starts to show us a more sustainable way forward, and the beginnings of

our „new horizon‟ thinking.

This report continues by using four topics as illustrations, within each of which run themes

of assets, resilience, prevention, early intervention and recovery.

„It will take bold leadership to invest in this strategy when everyone is so focused on making immediate savings. But of all the current strategies for dealing with the financial challenge, this has the greatest likelihood of reducing demand for healthcare, improving recovery rates when people become ill, providing sustainability in the longer term and being supported by the public.‟

Dr M Hannah (2010)

38

The Big 3...and the even Bigger Questions

This chapter focuses on three areas: Smoking, alcohol and obesity. Within each section we

describe the history of the topic, when it became an issue, and how it has been tackled over

previous years. We then go on to describe what we actually know about the topic, how

many people in Shetland smoke, for example, what are the trends, and what have we done

(with our partners) during 2011-12? We then describe some of the proposed actions for the

coming years.

But underpinning all of this are some difficult questions. Most people who smoke know the

harm it is doing to them and would like to stop. Most people who are overweight have tried

numerous diets or exercise regimes over the years. So what are the additional (or different)

ingredients/approaches that would really make a difference?

To build on the concepts we described in the previous chapter:

Self-empowerment

Self empowerment is a state in which an individual possesses a relatively high degree of

actual power – that is genuine potential for making choices.

Tones and Tilford (2001)

Self-esteem

How good you feel about yourself; your opinion of yourself.

Ewles and Simnett (2003)

Self-efficacy

Whether people believe they can change.

If a person feels confident in their abilities to perform a desired behaviour for a specific

setting, then they are more likely to engage in that activity.

Bandura (1977)

„I don‟t have the time‟

„I‟ve tried but I‟m no good at it‟

„There‟s nowhere to walk‟

39

Community confidence & resilience, social protection, social connectivity allows people to

take control of their lives, and gives people „survivability‟ – Harry Burns

In public health we often describe ourselves as agents of change....so how do we make

change happen rather than live with the status quo?

Smoking

Smoking is one area where it really feels possible, albeit ambitious, to eliminate the risk

factor of tobacco use from Shetland within a ten year period. The statistics are clear:

We have approximately 3000 smokers in Shetland

Of those in touch with smoking cessation services, approximately 200 set a quit date

each year.

Of these, approximately 100 actually quit smoking each year.

At this rate, it will take 30 years to make Shetland smoke free (assuming that new people

don‟t start smoking or that if they do then an equivalent number of people stop smoking

without any help from services).

If we multiply our success at smoking cessation support by a factor of three, and tackle the

issue of people taking up smoking, Shetland could be smoke free in just 10 years. This

doesn‟t necessarily mean increasing funding and tripling the number of smoking cessation

officers from one full time post to three, although it might do. It does mean having a vision

of a smoke-free Shetland, and a culture change to support that vision. It means focusing

our efforts on stopping people smoking in the first place, (primary prevention), and then

capitalising on all the contacts that healthcare, social care, community and other workers

and volunteers, have with people who smoke in supporting and encouraging them to stop

smoking; in giving the right messages; and if need be in referring them appropriately to

smoking cessation services. This means developing a culture that wants to have a smoke

free environment, and promoting the message that health improvement is everybody‟s

business alongside increasing health improvement capacity and capability across the whole

community.

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National Policy

The most recent policy documents which impact on this area of work are:

Beyond Smoke Free: Recommendations for a Scottish Tobacco Control Strategy

(2010) This document offered recommendations for a new Tobacco Control Strategy and

set out what we must do now as a nation to tackle the health inequalities which are fed by

smoking.

http://www.ashscotland.org.uk/media/3569/Beyond_Smoke-free.pdf

CEL 01 (2012) Health Promoting Health Service.

This Chief Executive letter encourages hospitals and the health service generally, to

promote health and enable well being in patients, their families, visitors and staff, whilst also

contributing to a reduction in health inequalities. It expects clinical teams to incorporate

health improvement into their day to day ethos and activities, taking advantage of

opportunities to change behaviours, especially amongst people most at risk of poor health.

In terms of smoking and tobacco specifically, hospitals are required to ensure dedicated

specialist smoking cessation advice within the hospital and commit to the development and

implementation of comprehensive organisational policies.

Epidemiology

We know more now than we ever did about the number of people in Shetland who smoke:

The Scottish Household Survey 2011 showed us to have a smoking rate of 19%. This is the

second lowest rate in Scotland, and still below the Scottish average of 23%.

However, when we looked at information extracted from the General Practice databases

(the EMIS system) throughout Shetland, a different (and probably more accurate picture)

arose. The EMIS databases record each patient visit and any actions completed in that

visit by the GP or other clinical staff attached to that practice.

We looked (anonymously) at patients of all ages whose smoking status had been recorded,

and categorised them into one of three groups: -

Never smoked

http://www.ashscotland.org.uk/media/3569/Beyond_Smoke-free.pdf

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Current smokers

Ex-smokers

The percentage of patients where smoking status was recorded was between 59% and

94% across practices. Overall, this is just above 86% of the Shetland population.

This told us that 20% of the population smoke. The difference between this and the

Household Survey figure may well be because those attending their GP are more likely to

be ill, and therefore to smoke. If we can get recording in primary care up to 100% we will

have a true and up to date figure for smoking in Shetland.

The dangers of smoking are generally well known through TV advertising and other

government initiatives. They include cancers, especially lung cancer, also chronic

obstructive pulmonary disease, heart attack and stroke. In pregnancy smoking decreases

the chance of fertility and increases the chance of miscarriage. Once the baby is born there

is an increased risk of sudden infant death syndrome in babies subject to tobacco smoke.

The above graph shows the percentage breakdown of the recorded smoking status for men

and women. The totals are as follows: -

Never smoked: 53%

Current smoker: 20%

Ex-smoker: 26%

The missing 1% is due to the effects of rounding the numbers.

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The above graph shows that there are more female smokers than male smokers until the

age of 25, when males are more likely to smoke than females. The number of young

female smokers has increased over the past few years, whereas young male smoking is in

decline.

Numbers who quit smoking and quit rates

During 2011-12, 235 people contacted the local smoking cessation services; 194 set a quit

date. Of these 181 were followed up, and 83 successfully quit at 4 week follow up giving a

43% quit rate amongst all those who set a quit date.

Smoking in pregnancy

The smoking rate of women when they first book in for ante-natal care in Shetland is 14.5%

(ISD 2010) which equates to 41 pregnant women. This is the 3rd lowest rate in Scotland

with the Scottish average being 18.8%. Disappointingly though this is only slightly less than

the overall smoking rate for Shetland; we might have expected lower smoking rates

amongst pregnant women in locally.

Estimated levels of chronic diseases and death

Chronic Obstructive Pulmonary Disease (COPD)

COPD is the only major cause of death on the increase in Scotland. On the basis of current

smoking rates and population predictions, it is projected to increase by 68% over the next

20 years nationally.

A paper written on behalf of the Scottish Government „Prevention of ill health in older

people – an economic analysis42 „ predicts the levels of COPD if we carry on as we are.

We know that smoking is a key risk factor for COPD, so, based on this report we can work

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out that if our smoking rate stays the same as it is today, in 2028 we will be seeing

approximately 285 cases of COPD each year, at a cost of around £920,500 per year. If we

can reduce our smoking rates by half, we could potentially prevent 40 cases of COPD in

Shetland and save in the region of £120,000 per year.

Similarly, if the smoking rate was cut by half, we would potentially prevent 4 cases of stroke

each year. If we can also reduce levels of obesity, high blood pressure, high cholesterol

and increase levels of physical activity, we can significantly reduce the number of strokes

each year in Shetland. So we begin to see how we could reverse the tide of increasing

demand for health (and care) services.

Key Targets

To reduce the percentage of adults who smoke from 15% in 2010 (as measured by

Scottish Household Survey) to 10% by 2015, and 5% by 2022

To reduce the percentage of adults who smoke in the two most deprived SIMD

quintiles in Shetland to match the overall smoking rate for Shetland by 2015.

To achieve the HEAT target of 104 inequalities related smoking cessation successful

quits at 4 weeks by end March 2014 (35 achieved by March 2012).

Historical data based on GP practice figures shows that the practices that cover the most

deprived areas in Shetland (as measured by SIMD) have higher smoking rates than other

practices. One action this year is to use more accurate and up to date information to

determine the current baseline for this indicator, and set a trajectory to reach the target.

Smoking Cessation – This has been more of a struggle in the last year as our number of

smokers reduces and we have to try harder to find and engage those people who still do

smoke. We ended the year very slightly behind target (35 out of a target of 38 at end

March 2012) but with a clear plan in place for reaching more of the „hard to reach‟. This has

already borne fruit – we have developed a voucher scheme in conjunction with the Shetland

Recreational Trust to support people stopping smoking with the opportunity to take more

exercise, and initial results suggest that this is having a positive impact. We also have

strong commitment through two large workplaces within one of the more deprived areas in

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Shetland to support us in delivering smoking cessation to staff groups within work time and

using work premises.

Tobacco Control Strategy 2012-22

Shetland‟s previous Tobacco Control Strategy ran from 2008 to 2011. During this time over

300 people within Shetland stopped smoking with help from the smoking cessation

services, and we now have one of the lowest smoking rates in Scotland. However, we

need these numbers to continue to fall and to make sure that young people, in particular, do