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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Four Circles of Population Health

In my previous blog in this series, I wrote about the ‘Pentagon Model’ which we have developed in Morecambe Bay to help us think about how we manage Population Health. The Pentagon approach actually forms one of four parts of some over-lapping circles, based on 4-Ps (Population Health Approach, Partnerships, Places, People Movement), which give a more holistic view of what is involved.

 

At the heart of the model we are working with, sits the people and communities who live in Morecambe Bay. Communities can be geographical, communities of interest (e.g. faith-based/workplaces etc), or transient (e.g. students). We are absolutely passionate that we do not do things TO people and communities, but rather, guided by the brilliant principle that ‘nothing about me, without me, is for me’, we do things with the people and communities we are trying to serve. We look to co-design, co-create and co-produce our services, because the services belong to the people. This takes culture change and some new thinking on our part and we are learning to work differently.

 

Our Venn-diagram gives us a framework with which to think about Population Health more clearly. The Population Health Approach Pentagon of prevent, detect, protect, manage, recover really forms one of the circles. Included within this, also, are a few other important factors. Firstly culture. If we don’t get culture right, then we don’t get care right. I’ve done three separate vlogs on the kind of culture we are trying to embed across the health and care system in Morecambe Bay – Joy, Kindness and Excellence. Secondly, we are redesigning work around various different health problems, for example, diabetes or respiratory problems WITH people who actually live with those conditions and use our services on a regular basis, building pathways for people that actually make sense and work for everybody. Thirdly, we are taking time to really understand the data available to us through many sources and using it to enable both the leadership team and our local teams to make informed decisions about where we need to focus our efforts to improve care.

 

More than ever before it means that we need to share resources with other organisations in order for us to be able to cope with current budget constraints. It also means that we have to think very carefully about where we align our resources. One of the issues for us in population health is that we have never really tackled the growing health inequalities in society. It is simply NOT OK that some people in this Bay die 15-20 years earlier than people who live 6 miles down the road. It is also NOT OK, that it is in these areas of higher deprivation, where we also see more complex medical and social problems, but do not allocate the money or the staffing to cope with the increased demand. And yes – it is true, that the problems are complex, and so money and resource is not the only answer, but it is definitely a part of the answer! If we’re ever going to make an inroad into changing the health of our population and tackling health inequality, we need to apply the triple value approach of Professor Sir Muir Grey – of how we prioritise our resources. (http://www.nhsconfed.org/blog/2015/05/the-triple-value-agenda-should-be-our-focus-for-this-century). Here is a short clip about it, if you’re interested! (https://vimeo.com/155569869).

 

Partnerships are absolutely key in improving the health of the population. There is so much cross over between county and city/district councils, the police, the fire service, the NHS in it’s various guises (including mental health, GPs, acute hospital trusts and community services), the CVFS and indeed the business sector. The relationships at strategic-leadership level and within each locality are the oil that allow us to work effectively together. It is only through honest, transparent vulnerability that we learn to trust each other and to share the resources we have to serve the needs of the population. As social care continues to sit under the remit of the County Councils and Health remains under the NHS, increasingly devolved into the regional Integrated Care Systems, without a deeper and more shared accountability and effective working together we will not have the necessary leadership to enable local team to transform the future of care.

 

This is where Place becomes really important. It is harder to get culture right, and build relationships that really work well if we’re always talking about “working at pace and scale”. As services are reconfigured, it is important that team structure allows for small enough teams to enable good working relationships to happen and that the necessary work is done to get culture right! I was in conversation with Professor Sir Chris Ham, CEO of the King’s Fund, and he is adamant that it is at this local neighbourhood level where the real change takes place, because this is where we are able to work with people and our communities in a very real way. That’s why we are so passionate about our Integrated Care Communities (ICCs). This is where, in a very relational way, traditional barriers between organisations are broken down and new bonds are formed in working together for local communities across the public and community-voluntary-faith sector (CVFS). There is a real danger that we focus so much on the ‘super structures’ and put huge time and energy into reorganising the system and lose sight, in the process, of the very thing we are trying to do, which is to make care better! Our ICC teams must feel the full permission and receive the resource needed to do this transformational work.

 

The reality is, however, that unless we have a people movement for improved health and wellbeing, nothing will change. The issues we are facing health and care-wise are incredibly complex and multi-faceted. In Morecambe Bay, we currently spend £1.20 for every £1 we receive. We are doing our very best to try and reimagine how we deliver health and social care, working more efficiently in partnership and redistributing resource where we can – but when we are all in financial deficit (and in our local NHS we need to cut our cloth by £120 million over the next 3 years – 1/5th of our total budget) when we have already had some eye watering cuts to the county councils budgets, especially in the area of public health, there is only so much we can achieve! We understand the frustrations that people feel when it comes to health and care, but we cannot fix it from within the system alone. There is a need for us all to recognise that things we could provide a few years ago may no longer be available or not within the same time frame as previously. It would be wrong of us as health leaders to simply make changes without the communities having a say. But for example, if we are to improve our Children and Adolescents Mental Health Service in South Cumbria (which is desperately needed), we might, as an example, need to do less knee and hip replacements……we simply can’t afford it all, with our current allocations of resource and staff, and therefore we need local people to work with us on this, and help us work out where our priorities should be. We know, if we don’t involve our communities in these decisions, complaints will go through the roof, which drives down morale and is utterly exhausting for teams to deal with. However, we are going to have to be brave in some of our decision making.

 

As a society, we also need to all be more healthy and well, taking care of ourselves and each other.Some might argue this is all down to personal choice. Of course, there is some choice involved – however, when you read the National Audit Office report (https://www.bbc.co.uk/news/education-44468437) into the huge difficulties Universal Credit is causing, and the Joseph Rowntree Foundation Report into Destitution in the UK 2018  (https://www.jrf.org.uk/report/destitution-uk-2018) then you begin to realise that it is easier to make healthy choices in some communities far more than in others. These are inconvenient truths, and need to be reflected upon with due diligence. There is a danger that we choose to work with highly motivated communities to improve health and wellbeing and actually make health inequalities worse. However, if we really listen to what is going on with local communities and work together, we can do some great stuff . Work from the University of Birmingham shows that if we can see a change in just 3% of our population, then this will have an effect on 90%. As the work in Canterbury, New Zealand shows though, this takes time and relationship – the process is actually more important than the end product. And for an under-resourced, already exhausted community, supporting any social movement requires investment at many layers. The NHS 5-year forward view and the learning from the Institute for Health Innovation both recognise that social movements/people movements are key to transformational change. We must press on with this work, and base it on a foundation of love and collaboration if we are really to change things together. So, this is why we are so passionate about really working with our communities, here in Morecambe Bay and will continue to host  and hold space for community conversations. We are talking about many things, from economic development,  to childhood, education, loneliness and mental health. These spaces are vital for us to connect together, hear one another, meet people who are different from us because it is only together that can reimagine a future that is good for the planet and socially just for humanity.

 

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A-Z of Health and Wellbeing

Tweet Happy New Year!   We often start a New Year with resolutions, things which we would like to change for the better. so, I thought I’d start this year of blogging with a vlog about my perspective on the A-Z of what affects your Health and Wellbeing the most.   It’s longer than most [Continue Reading …]

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Building Healthy Towns and Regions

Tweet The other week, I was phoned by a BBC producer to ask if I would take part in a discussion on the Victoria Derbyshire show about how we can build healthy towns. It’s partly due to the work we’re doing here in Morecambe Bay with our communities around being more healthy and well, especially [Continue Reading …]

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Hosting Conversations That Matter

Tweet In my last blog, I was exploring how some of the biggest determinants of our health and wellbeing have very little to do with healthcare at all. They are societal issues, with huge implications on how we live together. Issues like poverty, homelessness, loneliness and adverse childhood experiences are far greater drivers of health [Continue Reading …]

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A 3 Fold Approach to Population Health

Tweet Here in Morecambe Bay, we are trying to develop a strategy around Population Health – by that we mean we want to take a much broader view of the health needs of those who live in this area, ensuring that we try to tackle the disparities we see in the health of our population. [Continue Reading …]

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The Art of Hosting Good Conversations – Morecambe

Tweet Here is a video about a brilliant couple of days a bunch of us had in Morecambe, talking about how we discover what it is to be healthy and be part of a social movement to improve the health and wellbeing of everyone: Share This:

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Solutions Focused Thinking in Population Health

Tweet My last blog focused on how we can think about solutions instead of problems in the NHS. Well the same is true in thinking about the health of our whole population. Yes there are some problems! We have growing health concerns with obesity and diabetes. We have huge health inequalities. There are major issues [Continue Reading …]

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