Planetary Health and Person-Centred Care: A Vision for Scotland’s Future

An interview with Scotland’s Chief Medical Officer, Professor Sir Gregor Smith

Interviewed Ellie Kirkland for the Young Geographer magazine.

We know the NHS is under immense pressure and budgets are squeezed. Why does climate change need to remain a priority?

It’s really important that we see health as being linked to climate change. I see us facing four great health challenges in Scotland. First of all, the continuing threat of infectious diseases. Allied to that is the continuing presence of antimicrobial resistance and the rise of vaccine hesitancy and misinformation. The second is stalling life expectancies, particularly healthy life expectancies, that we see across many countries in Western society – and the deepening health inequalities that we experience. Thirdly, how we sustain health and care services in the face of a growing burden of disease. Health inflation and demographic changes challenge us every single year to keep up with the demands in the system.
But, the fourth challenge is the challenge of planetary health; that includes not just greenhouse emissions but also the loss of biodiversity and the risks associated with air pollution. This triple planetary crisis is absolutely interlinked with those first three challenges. We cannot separate them because if we don’t address the health challenges that will arise from the climate crisis, then we will see more, and different, infectious diseases. Those impacts are going to be felt mostly or disproportionately by people who experience health inequalities already, and this will challenge our health and care services even more.
So for me, the climate crisis is a public health problem that we have to face. We cannot separate the challenges that health and care services in Scotland face just now from the challenges that our own planet faces, because if we do, then we’ll not be prepared. We need a carbon neutral, climate resilient, sustainable and equitable health system for the future.

You became CMO in the midst of the COVID pandemic. Are there any lessons from that period that can be applied to how we tackle the health risks posed by climate change?

One of the strongest pieces of learning for me out of the pandemic response is that actually by improving the background health of our population, by reducing the health inequalities as much as we possibly can, when the inevitable next pandemic arrives on these shores then the population will be much more resilient to its effects. We need to get much better at preventing disease than perhaps we have in the past. By reducing the burdens caused by diseases and by reducing health inequalities we’re able to be more resilient to the threats that climate change poses. Something else I learned was the importance of communication, and the right type of communication. People come together and act for the good of broader society, and I think the threat posed by climate change on the planetary health crisis is such a threat that we need that collective action again. Communicating science is often difficult. We had a number of people during the pandemic response who are very, very good at it. If we can establish trust – and if we can communicate both the steps people can take and why investments are needed in certain areas rather than others – that, for me, feels like a crucial way to apply the lessons learned from the pandemic to other threats to human health.

Could you give us some examples of actions that are win-wins for the environment and healthcare?

If you look at some of the medicines that we use within the NHS, we know that some of those are potentially harmful to the environment. Asthma is a very common disease across Scotland, but sometimes it is not treated as well as it could be, unfortunately. Many of the inhalers that are used contain CFCs (Chlorofluorocarbons). We find that too many people are using their reliever inhaler too often and not using the preventer inhaler enough. If we can begin to rationalise how they’re using their inhalers and change the type of device so that it’s more environmentally friendly, then we’ve got a net benefit. First, and most importantly, improving the health of people with asthma by rationalising the approach to their care, but also leaving less of a footprint on the environment as well. There’s been some wonderful work started in Glasgow that’s now leading to a huge change in the way that we treat asthma in Scotland.
Another example is Green Health Partnerships. For me, the most important thing about this is that there are other ways of approaching disease states rather than just reaching for a prescription pad. The ‘green prescriptions’ that people have been issuing within these partnerships include taking part in groups where people spend more time in nature. We know the evidence suggests that the more time people spend in green space – or blue space for that matter – the better it is for their health, both physical and mental. We see community gardens beginning to be used across the NHS estate where people are spending more time in green space, participating in groups, very often reducing social isolation, helping to promote and empower people and develop their own agency in that space.The net benefits are again less utilisation of potentially harmful pharmaceutical resources, more impact with people actually being out there in the environment and all the benefits that that has on them. We can’t get away from the fact that the costs associated with that are much less and lead to a more sustainable financial model for the NHS, but still creating that net health benefit for people at the same time.

We’re now four years into NHS Scotland’s Sustainability Strategy, could you reflect onthe progress and remaining challenges? How do we get to a net zero health service?

I think when we launched the strategy, Scotland showed that we had huge ambition in this space and we were riding very high on the crest of COP26. Across Scotland, there are teams who’ve been amazing in delivering various aspects of that plan under really difficult circumstances. During that time we’ve faced a number of challenges, not least the fiscal challenges that we continue to face across Scotland. But it’s the enthusiasm of our workforce across the NHS which I think has led us to where we are now.
So, I think that we’ve made really good progress. For me, it’s time to ramp up activity and inject a little bit more urgency and resource around this so that we can face the threats of the future. Let’s use innovation as our friend in all of this. There is no one part of science, there is no one part of society who can do this alone. The only way that we are going to reduce the impacts of climate change in the future is finding intersections where we can work together. The best of science happens when we get different disciplines and different thoughts coming together in a big melting pot. I think that’s possibly the most exciting aspect for me as a public health clinician is how we harness all that brainpower that’s out there to reduce the impacts on our population’s health in the future.

I’m going to stay optimistic because I believe that people really want to make a difference in this space. I believe that society is coming to the point where it realises that it can no longer take the same approaches that it did in the past, that it has to change in order that we face some of these threats and reduce the impacts of them. I still firmly believe that we can make the changes necessary.