Chief Medical Officer's annual report 2024-2025: Realistic Medicine - Critical Connections

Chapter 1: Connection

Just over 30 years ago, I started my first job as a resident doctor at Glasgow Royal Infirmary with one destination in mind– to become a GP. I wanted to be part of my community, connecting with the people I was caring for.

I have been fortunate – not only did I find that sense of connection as a GP, I have found it in every team that I have worked in along the way. The sense of belonging that I have enjoyed is, I think, aided by feeling part of a team, where my contribution was valued and where I felt supported and trusted by my colleagues. This is especially important at the outset of our careers, but for many, this sense of connection and belonging is not as easy to find in the healthcare system today. We must improve this.

System pressures may tempt us to focus on increasing efficiencies and meeting targets. This is perhaps understandable given the unmet need that we witness in the backlog and I am grateful for the efforts being made to reduce this in a very challenging landscape. I am concerned, however, that if we apply this lens of efficiency inappropriately to all aspects of healthcare, we may lose that vital connection and provide sub-optimal, transactional, industrialised care instead. There is a very real risk that this loss of connection will prevent us from seeing the people we care for as they wish to be seen and understanding what matters to them. It is this transactional approach to care that can lead to overtreatment, potential harm, wasted resources and to decision regret.

I know how hard you are working to provide care that people value and I want to thank you for your continued dedication and effort on behalf of our population. You continue to make a vital contribution to people’s lives at times when they are often at their most vulnerable or anxious.

In April, the Scottish Fiscal Commission published its second assessment of the Scottish Government’s fiscal sustainability. Contrary to previous predictions, Scotland’s population is now predicted to grow due to positive net migration, rather than falling in the medium term.

The health of the population affects the sustainability of our public finances. Health spending is the largest part of the Scottish Budget. Based on current trends, health and social care spending is projected to rise from around 40 per cent of Scottish devolved public spending in 2029–2030, to almost 55 per cent in 2074–2075. This could pose significant issues for fiscal policy, but more importantly will reflect a rising burden of disease carried by people across society and disproportionately by those with greater socioeconomic disadvantage.

Health spending tends to rise with age, meaning an ageing population could lead to the need for more health spending in future. A greater proportion of Scotland’s population is predicted to be older over the next 25 years, and how the population’s health changes as it ages can influence the scale of health-related public spending. If we can support the people we care for to age well and remain healthier for longer, significant improvements in health could be achieved as well as supporting people to be economically active for longer too.

Much of the disease that we will face in future can be prevented and we must pursue this objective with urgency. The Scottish Burden of Disease study suggests that there will be a 21 per cent rise in illness experienced by our population by 2043, two-thirds of which is accounted for by cardiovascular disease, cancer and neurological conditions. However, health care systems – including ours – tend to have a much greater focus on treatment rather than prevention.

Cardiovascular disease (CVD) is the second largest burden of disease in Scotland, and the second largest cause of mortality after cancer, accounting for around 25% of all deaths. In 2021 alone, there were 4,478 premature deaths (in those under 75 years) from CVD. A subanalysis of the Global Burden of Disease 2021 study, published earlier this year, suggests that stalling life expectancy during 2011–2019 across many countries, was largely driven by increased mortality from CVD and cancers. Countries which maintained improvements in mortality from these conditions during this period maintained their life expectancy during the Covid–19 pandemic. Therefore, we must intensify our efforts to improve mortality, and the health resilience of our population, in these areas.

While landmark legislation to create a tobacco-free generation in the UK will further improve cardiovascular disease prevention, it will be insufficient to deliver success on its own. In response to changes in cardiovascular outcome data in 2022, the four UK Chief Medical Officers called for the restoration and extension of secondary prevention of disease and issued a challenge to reach populations that we have been unable to reach effectively before.

It is encouraging therefore that NHS Scotland and the Scottish Government have developed a programme with the intention of reducing avoidable CVD deaths by 20% over the next 20 years by addressing common risk factors; high blood pressure, high lipids (LDL-cholesterol), high blood glucose, smoking and obesity. This will ensure that prevention efforts are targeted to groups with historically low uptake. That includes addressing disparities associated with ethnicity, mental health and socioeconomic status.

It is critical that we intervene upstream of this disease by tackling the underlying issues that fundamentally determine health. This includes tackling harmful food environments and physical inactivity which contribute to rising levels of obesity – a precursor to chronic diseases such as diabetes, cardiovascular disease and many cancers. A study examining historic trends in weight estimates that 1.5 million people in Scotland will exceed the threshold for obesity by 2040. This predicted trend estimates that male obesity will increase by 5%, whilst female obesity will increase by 19%.

It is estimated that 10% of all health loss in Scotland is attributable to overweight and obesity with the annual cost to Scotland of obesity estimated to be £5.3 billion. In a joint statement, published in August 2024, the Scottish Directors of Public Health said: “A multifaceted, prevention-focused approach that improves the food environment through regulation, taxation, product reformulation, and affordability, is essential to addressing rates of excess weight.”

Creating a sustainable system

We must also change the way we deliver care to consistently provide careful and kind care, recognising the critical importance of continuity and relationship-based care in accounting for the biography as well as the biology of the people we serve. This can only be done as equal partners with our communities, viewing each person’s individuality and connecting with them through trust, continuity and shared decision making.

A new social contract with the communities we serve may assist the transition to this new model of care, underpinned by prevention of disease and with a strengthened primary and community care sector, comprised of interconnected multi-professional, multi-sector communities of practise, that use new data models to prevent disease and to focus on the planning of care.

Case Study: ANGUSalive

I was inspired to see first hand the approach being taken to prevention and proactive care in Angus, through a collaboration that connects the local Health and Social Care Partnership, Angus Council and the ANGUSalive culture, sport and leisure trust.

The “Be Active... Live Well” programme and “Healthy Steps Angus” health walks programme are excellent approaches that are having immediate benefits for the people taking part, and which support them to invest in their future health. These programmes are helping people create and maintain connections with each other and their communities:

“My family moved to Montrose two and a half years ago and I was unable to walk down to the beach. Just before my last class I managed to walk down to the beach and back up. This is probably my biggest health achievement in over a decade. I believe I will be able to reduce my reliance on my wheelchair and open up my social opportunities.” – Participant

“Health walks have been a lifeline since I lost my husband. I am now walking twice weekly with Health Walk groups and meeting new friends made out on the walks.” – Participant

The approach being taken in Angus demonstrates exactly how the principles of Realistic Medicine and Value Based Health and Care can encourage the sustainability we need. By prioritising preventative care that achieves the most meaningful outcomes for people we can prevent illness while optimising the considerate use of resources across the entirety of the population.

It is by practising Realistic Medicine that we will establish this culture and foster the conditions required to create a fairer, more sustainable health and care system. This approach helps support healthier lives, reduces unnecessary treatments and hospitalisations, minimising healthcare waste and ensures optimal use of natural resources, public funds and value for money.

Connection

Connection is the key to understanding and supporting the people we care for to live longer, healthier lives by focusing on disease prevention and healthy ageing. Connection is the key to tackling loneliness. Connection with nature improves our wellbeing. Connecting the teams we work with and the communities we serve is the key to better job satisfaction.

Connection binds us together. It shapes relationships, ideas and even the course of events over time. Connection fuels empathy, sparks creativity and helps to bring meaning to our lives. Social disconnection and detachment, however, can have wide-ranging and serious effects, impacting on our mental and physical health and our sense of wellbeing. We have all, I suspect, experienced times when we feel less connected to others, or have purposely detached in order to aid reflection or to recharge. But chronic, unconscious disconnection can lead to greater risk to our health.

“When we try to pick out anything by itself we find that it is bound fast by a thousand invisible cords that cannot be broken, to everything in the universe.” – John Muir

Here, Muir is emphasising the interconnectedness of all things in nature. He reminds us that we are frequently dwarfed by larger considerations. Nothing in the universe exists in isolation, including ourselves. Those “invisible cords” he mentions are the relationships and dependencies that link us and our natural world together: ecosystems, food chains, climate systems, even spiritual and emotional connections.

Muir’s reminder of our interconnectedness and the ripple effects of our actions resonate deeply with many of today’s pressing issues including:

• social inequality – inequality stems from the “cords “ connecting us being stretched. The impact can be seen in systemic inequalities, such as disparities in access to education, healthcare and basic needs – often for those who need our help the most, or discrimination because of ethnicity or personal characteristics. Addressing these issues requires us to recognise how societal structures and individual actions contribute to perpetuating or alleviating inequality.
• climate emergency – the idea that our actions come back to us as effects is evident in the environmental crisis. Individual and collective choices drive carbon emissions and deforestation. We can all see the impact of our choices on our planet, including extreme weather, polar cap ice loss, rising sea levels, and biodiversity loss. This highlights the need for global cooperation and shared responsibility.
• mental health awareness – the “invisible cords” Muir mentions align with the growing recognition of mental health as a shared societal concern as rates of emotional distress and illness increase. Supporting one another emotionally and creating connections with others can strengthen wellbeing across communities.

Muir’s words serve as a reminder that our interconnectedness is both a challenge and an opportunity. By acting with empathy and foresight, we can address these issues in ways that benefit everyone.

Empathy is the cornerstone of meaningful human connection and critical in ensuring that we provide careful and kind care with consistency. It breaks down barriers, fosters understanding and helps to create a more compassionate society.

Empathy, the ability to understand and share the feelings of another, is not merely a trait but a journey. Our stories and experiences, our biography, guide us through the complexities of human experience.

Empathy and human connection sit at the heart of what it means to be a health and care professional. To care for the planet, is to care for ourselves, our families and our communities; to be proactive in living healthily is not only investing in health for ourselves but contributes also to planetary health. This is the virtuous cycle of mutuality.

Conclusion

In my previous report “Taking Care” I suggested that leadership is insufficient by itself to create environments where careful and kind care can flourish in our health and care systems. Organisations are communities of people, not anonymous resources or assets, and ensuring that the natural commitment people want to give is released can only be done through creating a culture of mutual respect, trust and collective engagement. It’s our connectedness that’s important, characterised by collective responsibility and collaboration, rather than individual vested power and authority. We can do this by nurturing relationships with the people we care for, and with each other.

It is by following these principles, in articulating and protecting our shared purpose to provide careful and kind care, that we can align individual values and effort with organisational goals. By doing this, and protecting and strengthening these connections, across communities and organisations, we will realise the full potential of our workforce in health and social care and maximise the benefit to our citizens.

Earlier this year, I published a compendium of case studies (The Realistic Medicine Casebook) showcasing exemplar high value approaches to providing Realistic Medicine. Those case studies show how health and care professionals across Scotland are connecting and collaborating with colleagues, how we are fostering a culture of stewardship – where we take responsibility for the resources we use, and most importantly, how we are connecting with the people we care for through shared decision making, to reduce waste and harm and achieve the outcomes that matter to them.

I am optimistic and encouraged that practising Realistic Medicine is clearly helping us to connect and establish the culture and conditions required for a fairer, more sustainable system that is there for us all when we need it.