1. Changing children’s lives -how to deliver concerted action Edinburgh 14 th September 2012

2. 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

3. Life expectancy trends Portugal Scotland

4. Infant mortality trends 1848-2000 Source : Birth Counts, 2001 England & Wales Scotland

5. All cause mortality in Scotland in European context M ales age 1-14 years Age-standardised mortality per 100,000

6. Male mortality 15-75 Scotland and 15 other European countries

7. Female mortality 15-75 Scotland and 15 European countries

8. Workers in the 1950s

9. 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

10. Do social conditions determine the incidence of disease? u For centuries they have and they still do in the developing world –Plague, leprosy, polio, diphtheria, typhoid, tuberculosis –BUT in the developed countries u It is how we respond to social conditions which largely determines our risk of chronic ill health

11. Income deprivation - Liverpool

12. Income deprivation - Glasgow

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

14. Aaron Antonovsky 1923-1994

15. “.....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....

16. For the creation of health........the social and physical environment must be: u Comprehensible u Manageable u Meaningful u......or the individual would experience chronic stress

19. STRESS AND GRADE OF EMPLOYMENT: MEN Salivary Cortisol Time of Day Steptoe et al. 2003, Psychosomatic Medicine, 65, 461-470

21. Environmental determinants of inflammatory status CRP (median) mg/dl affluent deprived

22. Inflammation in plaques Inflammatory cells MMPs, IL-6, IL-15, IL-18, CRP Lumen Core Cap Thin Fibrous Cap InflammatoryCells SMCapoptosis Degradedmatrix Unstable cytokinesMMP

23. 0 1 2 3 4 5 00.511.522.533.544.55 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

24. Adipocyte programming insulin resistance, inflammation and ALP Adipose stores NEFAs liver CRP SAA IL-6/IL-6sR TNF-  TNF-  sR-I triglyceride Low HDL small LDL Atherogenic Lipoprotein Phenotype Pro-inflammatory state skeletal muscle Insulin resistance

25. Persistence hunting

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

29. Adverse childhood events risk of alcoholism Hillis et al 2011

30. Adverse childhood events risk of perpetrating violence Boys experiencing physical abuse Duke et al 2010

31. Risk of heart disease and early adversity

32. Health Deficits approach u 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

33. Health Assets u 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

34. Strengthen Community Actions u 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.

35. The pathology of poverty 24 th European Congress of Pathology Prague 11th September 2012

36. A System

37. Functions of a system u To allow a few people to control many –eg. Captain of a ship u Allows production of a great deal of the same thing –Goods or services u Needs to create consumers or clients –ie Creates need

38. The multi service system

39. Associations of citizens Decide what the problems are Decide how top solve them Organise to implement the solution

40. Social connectedness u 148 studies comprising 308,849 participants, high levels of social integration conferred a 50% increased likelihood of survival. u Complex patterns of social integration conferred a 90% increase in survival. u Simple indicators such as living alone versus living with others conferred a survival benefit of only 19%.

41. SG LAs NHS 3 rd Sector Enhancing social connectedness 1. Light the fire 2. Build communities Help to connect people Coproduction

42. Coproduction The 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.

43. u Early years u Youth alcohol and offending u Rehabilitation of offenders u Employment and local entrepreneurism u Physical fitness u Support for the elderly A life course approach?

44. Improvement science u W Edwards Deming (1900-1993) –“In God we trust, all others must bring data” –“By what method? Only the method counts.” u Don Berwick –“Some is not a number. Soon is not a time.” u Scottish Patient Safety Programme –“By how much and by what method?”

45. Executing the change u There are many change theories and models. We must choose a small number of improvement methods and stick with them for the long haul. u They must all be based on the simple formula of aims/measures and changes. u Our selection may be;  Collaboratives  Benchmarking and competition  User/ Community empowerment  Performance management u The choice must be explicit and evidenced.

46. u Agree outcomes –For pregnancy, early development and preparedness for school u Agree interventions to achieve these outcomes –Five or six evidence based interventions for each stage u Apply interventions consistently across the whole population u Measure progress and react to the data An early years collaborative

48. Outcome Aims u Mortality: 15% reduction by 2015 u Adverse Events: 30% reduction u Ventilator Associated Pneumonia: 0 or 300 days between u Central Line Bloodstream Infection: 0 or 300 days between u Blood Sugars w/in Range (ITU/HDU): 80% or > w/in range u MRSA Bloodstream Infection: 30% reduction u Crash Calls: 30% reduction

49. Scotland HSMR – 9.3% reduction

50. % compliance with multi- disciplinary rounds and daily goals 74% 93% 19% improvement

51. VAP rate (per thousand ventilator days) 9.11 3.54 61% reduction

52. General ward C.Difficile rate (per thousand patient days) 1.15 0.12 90% reduction

53. Jimmy Reid 1971

54. 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....” 