Health and wellbeing – How do we get it right? by Catherine Mackereth and Michelle McCoy

Not one of us has had a choice in the life circumstances into which we were born. We are born in a country, with particular parents and with certain advantages and possible disadvantages – and this can have a lifelong impact on our health and wellbeing. We know that some are born with genetic conditions that have a huge effect on their lives; those brought up in poor housing conditions are more likely to suffer from respiratory diseases; children brought up in care may have less resilience to overcome difficulties (which is not to say that many don’t overcome them); and many are not able to make the most of opportunities because of the difficult and challenging circumstances they find themselves in.

Within Public Health, a discipline that has a major focus on seeking to improve health and wellbeing at a population level and reducing inequalities, a model that we often use to describe these situations is the Dahlgren and Whitehead rainbow (below). This, since its publication, has become a frequently used model for describing the underlying causes of ill health in the population and provides a helpful framework on which much of the health improvement work we are involved in is based. It offers a social model, which focuses not just on the individual lifestyle factors that impact on health, but on the wider socio-economic, cultural and environmental conditions, which make a huge difference to our health and wellbeing.


Underlying these differing life circumstances are inequalities which may be income, education, housing, environment or social conditions. The graph below shows how health and social problems are worse in more unequal countries. These inequalities can be found with regards to child wellbeing, levels of mental illness, drug use, life expectancy, infant mortality, obesity, teenage pregnancy, education, to name just a few.


These inequalities are not inevitable, and therefore should be tackled in order to ensure people have opportunities to improve their health and wellbeing. It is the role of Public Health and all our other partners to address these issues. It is not an easy task nor can it be undertaken by one agency alone.

Improving health and wellbeing must be supported at all the different levels identified in the rainbow model above. At an individual level, we need to understand why people behave in the way they do. Much of our work in improving the populations’ health and in providing preventive services is about supporting people to make their own positive life choices. However, having the ability to make choices is something not everyone has to the same extent: the very reason why we need to support people. For example, at one level, people have the choice as to whether to smoke or not. But if you are under stress, giving up smoking might be one thing that is too difficult to contemplate: we know that will power is a finite resource, and if you are juggling with a crisis, then all your efforts need to go into solving that crisis. And that is not even considering the physical addiction and the impact of tobacco withdrawal. Remember, very few people actually want to be addicted to cigarettes.

Health and wellbeing also needs to be addressed at a family level. For example, we know that some children are disadvantaged at school entry because they do not have the necessary emotional, social and cognitive skills which enable them to take advantage of the opportunities available from education. Support for parents can provide the self-confidence and self-efficacy to help counteract these difficulties, so that children can have the best start in life. This is extremely important for future life when these children become adults, and affects further wellbeing and subsequent use of health and social care services.

There are many approaches to supporting improved outcomes for population health. For example, at a wider level it is important that environmental issues are addressed. Creating enough green space for children to play or adults to walk and be physically activity can have a major impact on health and wellbeing – as can having nutritious food available locally, or accessible social activities. Having enough money is also a key element of trying to live healthily. In times of job insecurity and rising costs, this can be challenging, so ensuring access to the right kind of advice for claiming benefit, offering support to complete job applications, provide welfare rights information to support people to claim what they are entitled to, providing accessible health services and health information which is easily understood, is vital.

If, as a society, we are to reduce the burden on health and social services, we must work together to prevent and mitigate against the circumstances which act together to limit the ability for communities and individuals to achieve optimum health and wellbeing. There is a lot that can be done to support people’s health and wellbeing, and this must be underpinned by looking at what people themselves really want, not just assuming that we, as health professionals, know what is best for them. We need to listen and understand where people are coming from, and do that with compassion. We all want the freedom and autonomy to do what is best for ourselves, and we need to make sure we support people in achieving that for themselves.

Catherine Mackereth is a Consultant in Public Health and Michele McCoy is a Consultant in Public Health and Interim Director of Public Health at NHS D&G


A Message from the CMO @CathCalderwood1

I’m delighted to have been asked to contribute an update to the Dghealth blog.

This year has got off to a busy start for me with the launch by all of the four UK CMOs of the consultation on alcohol guidelines for lower-risk drinking, and my first annual report as Chief Medical Officer for Scotland, calling for a debate on Realistic Medicine.

The guidelines advise men and women not to regularly drink more than 14 units a week, spread drinking over three days or more if you drink as much as 14 units a week and if you want to cut down how much you’re drinking. A good way to help achieve this is to have several drink-free days each week. It can be a bit tricky to understand and remember how much alcohol is in drinks, and how this can affect our health. The low risk guidelines can help with this, if you choose to drink. No-one can say that drinking alcohol is absolutely safe, but by sticking within these guidelines, you can lower your risk of harming your health if you drink most weeks. I was pleased that the new guidance also takes account of the harmful effects of binge-drinking, and brings the rest of the UK into line with Scotland by advising women not to drink any alcohol during pregnancy.

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One of the ways I try to be accessible is via my blog and Twitter feed – it was interesting to see the comments on twitter around the alcohol guideline launch, ranging from welcoming to “killjoy”. Change is always going to cause a reaction – but since the guidelines are in response to evidence of the risk of alcohol causing cancer the UK CMOs have to get our message across, however difficult that may be, so people can them make their own informed choices.

The reaction to my annual report on Realistic Medicine has been more universally positive, in the media and through feedback on twitter and my blog. The report contains the traditional publication of “health of the nation” issues examining a range of population health surveillance data and outbreaks of disease etc but the key theme is ‘Realistic Medicine’ and what this can mean for the challenges that face doctors as a profession and in healthcare. I launched the report at the Western General Hospital in Edinburgh with Dave Caesar, Consultant in Emergency Medicine, NHS Lothian and Dr Caroline Whitworth, Renal Consultant, Royal Infirmary of Edinburgh.

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I followed this up with a discussion about the questions I raise in the report with a group of about 20 doctors from NHS Lothian. This is the beginning of engagement I want to undertake across Scotland to hear views of doctors who are well placed to come up with the answers to how we improve shared decision-making; ensure we deliver person-centred care; reduce unnecessary variation in treatment and outcomes; as well as reduce harm and waste (including over-treatment) for the people doctors treat. My team produced a very helpful infographic setting out these questions and we have a range of materials for anyone in the profession who wants to discuss this among themselves and feedback to me via the clinician survey.

I would welcome feedback from everyone on the report so l can use it to inform health policy. My role and that of my team consisting of the Deputy Chief Medical Officer, Dr Gregor Smith and senior medical officers and speciality advisers is to provide the clinical voice in decision-making. As healthcare professionals we have useful knowledge and expertise to guide policy and our input is vital. I would welcome your input to help us to carry out that role effectively. I can be reached in a number of ways: 



Twitter: @CathCalderwood1 []


CMO on LinkedIN



Alcohol and Wellbeing by Andrew Carnon

A blog of two parts, first a glimpse into a common public health topic and then something I hope may be a bit different.

A retired doctor friend told me a story. He was invited to be on an interview panel for a consultant appointment in the 1980s. The interviews were held in the new Boardroom at Crichton Royal Hospital. After the candidates had been seen in the morning, a good lunch was provided and then a black-clad waiter with white gloves opened a wood cabinet from which he produced a silver tray with sherry and glasses which were offered around the panel and successful candidate for a celebratory drink. Different times now!

For years alcohol was one of the few causes of death that was increasing in Scotland. Completely opposite to the success stories in heart disease, stroke and cancers through better treatment and prevention, deaths from alcohol seemed to be going through the roof. Looking at the chart, you see that alcohol-specific death rates for females and males have been consistently higher in Scotland than in England & Wales. The female rates are lower than the male rates, and the female rate for Scotland is actually similar to the male rate in England & Wales. And as well as these very specific deaths, there are many more where alcohol is a contributing cause.

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Death of course is the most severe outcome, but alcohol can also lead to a host of other problems impinging on the NHS, from long-term harm to health, falls and injuries, to domestic violence, unsafe sex, unwanted pregnancy, and problems at work or job loss.

Why are alcohol-related deaths so high in Scotland and what can be done about the problems?

Lots of things are tried or proposed, for example:

  • Local or national awareness-raising campaigns
  • Opportunistic advice when patients consult a health professional
  • Brief interventions on alcohol in settings like Accident & Emergency
  • Alcohol and drug treatment service
  • Attempting to restrict availability of alcohol through the licensing system for off-licences (supermarkets, shops selling alcohol) and on-licences (hotels, pubs, clubs)
  • Proposed minimum pricing of units of alcohol.

Do these work? Unfortunately there’s little evidence that campaigns make any more than a whit of difference. I suspect they’re more about salving consciences that something is being done, rather than actually doing it.

By far the most effective public health actions tend to be the big population measures, like tackling availability or price of alcohol, but these invariably run into strong opposition and can become mired down in commercial or contrary interests. The derogatory term ‘nannying’ is often used.

Are the opposite views unbridgeable, depending on whether we give more weight to preventing harm or to protecting individual autonomy for people to harm themselves if they choose? Are there any easy answers at all? At least there’s some comfort that rates seem to be falling in recent years.

Andrew carnon 2Sometimes questions like these seem so difficult that I’m going to segue instead into another public health principle, increasing wellbeing. The Edinburgh book festival ( is one of the highlights of my own year, a real heart-sing event. Last month at the festival my mind was stimulated by (amongst others) philosopher Roger Scruton, journo Jeremy Paxman and Rebecca Mead of the New Yorker magazine.

Rebecca Mead’s theme was that reading classic literature has lifelong benefits. That set me wondering what are possible benefits of reading to busy NHS staff? I’m talking here about reading fiction, rather than the day’s deluge of work emails or NHS D&G’s required reading sent out to all staff, as these are, of course, supposedly non-fiction!

What benefits might there be? I can think of:

  1. Learning about how health professionals do their jobs, grapple with ethical questions or deal with lack of resources.
  2. Learning about patients and how diseases or disabilities affect their lives.
  3. Getting information about different lifestyles we might not have experience of ourselves.
  4. Getting inside characters’ heads might help to develop the subtle trait of empathy.
  5. May help improve communication skills (can develop our own vocabulary and range of expression and help us see different communication options and styles).
  6. Possibly (if Rebecca Mead is right) may enhance our own wellbeing, personal growth and development of wisdom throughout life.

I’m sure book lovers amongst you will think of other benefits as well. And the best thing is that all of this learning can be achieved in comfortable home surroundings (with one small glass of favourite tipple if you must), and without having to attend the latest recommended professional development course.

And so, back to the beginning. One thing reading can do is give you wider perspectives and individual insights into alcohol use. Pharmacologist Ronald Siegel thinks it’s a universal human drive to want to get ‘out of one’s head’ with mind altering substances. It seems to be so persistent through history that he equates it with our drives for food, sleep and sex. Could that be right? If so, attempts to control or price alcohol to reduce problems might not work.

Getting out of one’s head to an extreme degree is portrayed by a number of authors. I can’t help drawing attention to a couple of books set in Russia, where protagonists become drawn into a culture of regularly drinking to oblivion – both are fantastic reads quite apart from their alcohol insights: Among the Russians by renowned travel writer Colin Thubron (a previous Edinburgh Book Festival speaker) and Consolations of the Forest by French author Sylvain Tesson.

And just to finish on getting out of one’s head through drugs rather than alcohol, there’s a stunning short story collection: Julia and the Bazooka by Anna Kavan, who was a heroin addict for much of her life. The bazooka is a euphemism that Kavan uses for her syringe which went with her everywhere. The stories give a powerful insight into what life must be like for a dependent opiate user.

Oh and if you’re already a bibliophile or any of this has whetted an interest, the Wigtown book festival is in a week’s time…

Andrew Carnon is Joint Interim Director of Public Health at NHS Dumfries and Galloway