Goldfish and What They Teach Us!

Last week, I had the privilege of listening to Prof Sandro Galea, from Boston State University talking on the subject: “What do guns, obesity and opiates have in common?!” It was an amazing walk through the world of epidemiology – and the answer? Well – all three things are hugely important problems, they are all complex and therefore simple solutions cannot fix them! 

 

Virchow, one of the earliest and most influential thinkers in the realm of Public Health famously said, “Medicine is a social science and politics is nothing else but medicine on a large scale.” Sandro Galea takes this idea and modifies this slightly, suggesting that, in fact, politics IS health on a large scale. In other words, if we don’t get health and wellbeing (of ALL people and the planet) written into every policy, then we will never tackle the huge issues of health inequality and environmental disaster. 

 

Sandro gave an amusing analogy about his pet goldfish. He told us that every morning, he goes downstairs and sees his lovely goldfish swimming in their goldfish bowl. He cares for them, makes sure they are well fed, doing their exercises, having time for mindfulness to build resilience and ensures their contraceptive needs are catered for. Sadly, one morning, he goes downstairs and finds all his goldfish are dead. He’d forgotten to make sure the water was clean. The fish were, in effect, swimming in a cesspit (needless to ask whether or not fish are meant for a glass bowl!).

 

He has developed several principles when it comes to thinking about epidemiology. Principle number 5 states: “Small changes in ubiquitous causes may result in more substantial change in the health of populations than larger changes in rare causes.” His goldfish illustration shows that the goldfish are surrounded by water and everything they do is influenced by the QUALITY of the water they live in; therefore water is a ubiquitous factor in influencing the fish and needs to taken into consideration EVERY TIME we want to improve the lives of the fish. His point is this: if we don’t care for the environment and the external factors that give us life and wellbeing, then our other little interventions are futile. The problem is that we spend so much of our time making interventions that we can measure and feel successful about, like giving people statins, getting kids to run a mile a day, encouraging breast feeding, getting people through the ED in a timely manner or even giving them smart technology to nudge them towards better health outcomes, but we pay little attention to tackling the much bigger issues of poverty, poor housing, or air pollution.

 

The biomedical model for tackling the huge issues of population health has failed and will continue to fail. Our politics and economic model is broken! We have simply not written health and wellbeing into every aspect of our lives and have developed patterns of education and work that are actually doing more harm than good and driving health inequalities and the health of our planet in the wrong direction. Therefore, where there is evidence that policy is actually making health inequalities worse, or damaging the environment, we must challenge them with the evidence base, and plain common sense!

 

I do believe that communities can together make a massive difference, and increasingly I recognise just how vital policy is in helping us shape a just and fair society and in stewarding an environment, which is sustainable for the future. Policy and law can be love-fuelled and compassionate, and they need to become so, because politics IS health and we need to re-imagine it as such.

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The Four Rings of Leadership in Healthcare

I went to London a couple of weeks ago for the IHI (Institute for Health Innovation) conference in London – Quality Forum 2017. The focus was on Quality and Safety in Healthcare, with some hugely surprising and refreshing perspectives from around the world. It was absolutely great and I learnt loads. I’ve tried to distill my learning from the time into a single sheet diagram. My hope, over the next few blogs is to unpack this a bit more, but here is a very brief summary:

 

If we want to have excellent, safe and financially sustainable health systems, we need four key ingredients, with the patient and their family at the heart/centre. The most important factor in providing safe and high quality care is a CULTURE OF JOY! I love this. I love that an institute based in Harvard, with research from across the world, is able to say this so clearly. If we have happy teams, we provide the best care. It’s simple! A culture of joy has three key elements: firstly the team needs to have a sense of camaraderie (we’re in this together and we love each other and take care of each other), secondly the team needs a sense of purpose and thirdly the members of the team need to feel trusted to do their jobs.

 

Alongside this culture of joy, there needs to be a SOCIAL MOVEMENT, both within the staff and in the wider society. A social movement relies on structures in which power is ceded and personal and corporate agency (responsibility and action) can flourish. There also needs to be a sense of CONTINUOUS LEARNING, in which all partake, every voice matters and no question is too stupid. In Toyota the staff make over 2.5 million suggestions each year! No wonder they are continually improving. And fourthly, there needs to be an agreed focus on QUALITY AND SAFETY, which entails several aspects.

 

All of this depends on a new kind of leadership that is first of all humble, able to cede power and deal with significant complexity and ‘not knowing’. When financial constraints are tight, or huge savings have to be made, it can be tempting to start rationing and cut services deeply. This may balance the books, temporarily, but it destroys every thing you are trying to build, demoralises staff, ruins your culture and breaks trust with those you are trying to serve. The challenge is to begin to hold our nerve in the midst of extreme pressure and do what we know is right, backed by the best evidence available to us – and this, believe it or not, actually makes us financially sustainable. I am going to really enjoy unpacking this more and revisiting my learning over the next few blogs, but the above should hopefully fuel some thinking in the mean time.

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