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In Scotland we aim to increase life expectancy by 5 years in the next 10 years and decrease health inequalities.
These ambitions are bold. If life expectancy trends continue, Scotland will fall further behind the rest of Western Europe. Although premature mortality continues to fall, the trajectory of our improvement is currently more modest than that being achieved by other countries. And despite all efforts, health inequalities continue to grow. The gap between the rich and the poor is widening, with the richest 20% now living 10 years longer than the poorest 20% in Scotland.
A fresh approach: health creation
Albert Einstein defined insanity as ‘doing the same thing over and over again and expecting a different result.’
The excess mortality in Scotland requires something new to be done. It may partly stem from the social breakdown and loss of jobs when heavy industry (dominated by shipbuilding, coal mining and steel) declined, particularly in West Central Scotland in the latter half of the 20th century. Those affected were given housing and benefit, and remained predominantly in the region. Although the collapse of heavy industry happened in other countries in Europe, for example, Katowice in Poland, alternative suitable work was found and the sense of control, and community that goes with purpose and employment was preserved. The net result is that Scotland's excess mortality when compared with the rest of Europe can be partly attributed to causes such as violence, drug misuse, alcohol excess and suicide. Interestingly, similar patterns of excess mortality have been noticed in other population groups observed to suffer a loss of control or purpose, including the Aboriginal population in Australia.
To produce the necessary step change in life expectancy desired we must get it right for individuals and communities. We must refine what we are doing and change the culture. Aaron Antonovsky's work looked at the relationship between stress, health and well-being. People are more likely to remain healthy if we can identify and support the assets they and their community possess and use them to embed health-promoting behaviours. The over-riding legacy ambition for the Commonwealth Games 2014 is to help and inspire people and communities to be active.
Preventative medicine: good medicine
Health promotion, and preventative medicine, is a good medicine. In Scotland there is a shift towards preventative medicine, which is person centred, evidence based and effective. Health promotion represents a preventative spend, investing to save money and improve health outcomes. National Institute for Health and Clinical Excellence (NICE) calculated the quality-adjusted life year for a physical activity brief intervention to be £20–£440 which represents outstanding value for money.1
Success has been achieved in shifting the culture and attitudes to drink driving, the wearing of seatbelts and smoking, through legislation and sustained investment. Similar strategies are required if we are to succeed in tackling physical inactivity, obesity and alcohol excess, which remain as causes of unacceptable levels of mortality in Scotland.
Low fitness is one of the most powerful predictors of health outcomes. Steven Blair has had no challenges to his data showing that low cardiorespiratory fitness causes more unfractionated mortality than smoking, alcohol and diabetes combined.2 ,3 It is generally agreed that mortality can be reduced by 30%, and a risk reduction for many chronic diseases of around 20–40% is evident with regular physical activity.4 ,5 Additionally, regular physical activity can help prevent obesity, and prevent and treat many of the complications of obesity—if you are overweight or obese, regular physical activity can offset many of the associated risks.1
Regular physical activity maintains and creates health. It improves physical health, mental health outcomes and quality of life. It also improves function and thus increasing levels of physical activity in Scotland is one of the most important ways to improve healthy life expectancy in Scotland.
We aim to increase the proportion of adults meeting minimum physical activity recommendations from 39% to 50% by 2022, and to embed health creation, and physical activity systematically into the National Health Service in Scotland and into public policy.
To achieve these aims we must have clear methods. Huge success has been achieved with the application of improvement methodology to find things that work and replicate them at scale.
How can we make it normal to be active? Public health can be everyone's business. Seven Investments that Work for Physical Activity6 details the merit and a route map to collaborate with colleagues in education, transport, urban design, sports systems and programmes, the media and others to drive progress. A National Delivery Plan for Increasing Physical Activity currently being developed will apply this to Scotland. Each policy area has a substantial contribution to make, to improve levels of physical activity. The need to mobilise and integrate community resources is key to this process. We need to work with these communities, rather than imposing policy on them.
The National Health Service
There is momentum behind promoting physical activity for health in the National Health Service (NHS). The NHS Chief Executives group, the Academy of Royal Colleges Scotland, The Royal College of General Practitioners Scotland, the Allied Health Professions Directors Groups and the Faculty of Sports and Exercise Medicine are among groups committed to taking this forward.
Every healthcare professional should offer the best care for every patient every time whether this is in the form of tablets, or advice on health behaviour change. For example, surgical preassessment clinics ask routinely about alcohol consumption and smoking status. We should also ask about physical activity level and diet. Asking about physical activity and diet in primary care, medical outpatient clinics and during hospital admission should be routine, with appropriate advice available. It should be viewed as a vital sign, as important as taking a pulse and blood pressure. Both brief advice, and brief intervention have been judged as cost effective by NICE and medical care should reflect this. Electronic tools are being developed to facilitate this.
NHS Education for Scotland and the Board for Academic Medicine have committed to make teaching on physical activity recommendations, accurate assessment and appropriate brief advice an integral part of undergraduate and postgraduate teaching for doctors, nurses and allied healthcare professionals. We will look to create two consultant posts in Sports and Exercise Medicine in 2013.
NHS Chief Executives have committed to deliver a Health Promoting Health Service. A culture of Healthy Working Lives within the NHS can improve productivity, and decrease sickness absence. Physically active individuals take 27% fewer sick days.5 Health promotion within the workforce should be supported. Maintaining health and function in the increasing elderly population is vital. We must join Fauja Singh, the 101-year-old marathon runner in exploding the myth that you can be too old to exercise, and establish solutions for healthy active ageing.
Increasing levels of physical activity is a cornerstone to improve the health of our nation. Each patient encounter is an opportunity for every individual and team to make a difference.
We can increase life expectancy by 5 years in the next 10 years, and decrease health inequalities. To achieve this, a fresh approach is required, creating health and maximising the assets our patients, health professionals and communities possess.
The authors wish to acknowledge the input of Dr David White, Dr Mike Dunlop and colleagues at NHS Health Scotland and SPARColl in the preparation of this article.
Contributors The article was conceived by AM. The main manuscript and metadata were drafted, revised and edited by both HB and AM.
Competing interests: None.
Provenance and peer review Commissioned; internally peer reviewed.
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