Here are some excerpts from a speech I gave recently at Lancaster City Hall about how in a time of crisis, we can either turn on each other, or turn to each other (my friend Mike Love gave me that line!). When we turn to each other, unimagined possibilities become the fuel of hope for a better future for us all. I broke the 20 minute speech into just over 6 minutes – sorry if it’s a bit clunky, but I hope you get the gist!
Everybody knows about the Gender Pay Gap – it’s well publicised and very much in the public domain for discussion – and too right! – How is this even still an issue? It it is quite simply wrong that women should earn less than men, any time, any place, end of discussion.
Well the same applies to the North-South Health Gap. What I find particularly irksome about this issue, is that people tend to roll their eyes and say that it’s all playing politics. No! No it isn’t. This is not about politics. This is about Social Justice!
It has been well documented that for over 40 years, the health of the people of the North of England has been significantly worse than that of people in the South and our life expectancy is worse. It is a complex issue and is highly linked to deprivation and poor housing conditions in the urban areas. The gap was narrowed during the early part of this century, but the health reforms made to the NHS have seen massive cuts to public health and social care budgets, disproportionately affecting the North. To make matters worse, the funding formula that is used by the Department of Health to determine how and where money should be spent, deliberately favours the rich and the well and and that means that head for head of population, the North does considerably worse than the South in terms of how much resource is made available. This is even true of how many staff are given proportionally to the North compared to the South. This is just ludicrous and is simply not fair. How can it make any sense at all to spend more money in areas where the population is more healthy and people have a significantly better overall life expectancy already? Are we to believe that Southerners are more important than Northerners, just as the pay gap would imply that men are more important than women?
The savings being asked of the Northern STPs (Sustainability and Transformation Plans) at a time in which we are already struggling with the huge cuts previously mentioned, and starting from a significant deficit in terms of our health outcomes, is meaning that the health and wellbeing of the people of the North will suffer further. I am not suggesting that we can not work more efficiently and collaboratively within the public services, nor am I suggesting that the people of the North do not need to take greater responsibility for our own health (although it is well known, that when you are more deprived, you are less likely to have the mental wellbeing to make positive choices about your own health). What I am saying is this: whatever the budget allocations may be; let them be fair!
Yes, it is time for us to tackle the health problems across the North, and we will do so together as the people. Maybe we don’t have carte blanche any more and have to reassess what we think might be available in terms of health care provision. But what we would like is to be able to make this journey by starting on a basis of equality with the South. No more North-South divide. No more unfair funding calculations. No more political games. Social-Health Justice for all, now.
For further information, you can read:
https://academic.oup.com/jpubhealth/article/37/1/34/1556643/Grim-up-North-or-Northern-grit-Recessions-and-the
https://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/inequalities-in-life-expectancy-kings-fund-aug15.pdf#page2
http://councilportal.cumbria.gov.uk/documents/s50047/STP%20April%20submission%20for%20Lancashire%20and%20South%20Cumbria.pdf?nobdr=2
On Friday night, watching comic relief, I got quite excited as the total neared £50 million – I turned to my lovely wife and said – ha – there now, we can plug the gap in our local health economy for next year! (Obviously the money is desperately needed in many situations across the UK and Africa, so I wasn’t being flippant), but – that’s the target we’ve been set by the government in Morecambe Bay – save £50 million pounds – one tenth of our budget in 1 year!! Sure thing! The public just love to hear about cuts! Comic relief – you have to laugh, or you’d cry……..but the situation isn’t really very funny and yet, if we don’t head into the fray with some joy and hope in our hearts, we will become wearied very quickly.
Let me frame this problem by stating something we must then put to one side. Professor Don Berwick, health advisor to Barack Obama, and president of the IHI (Institute for Health Innovation at Harvard – a clever man by all accounts) recently stated very clearly to the Department of Health that it is quite simply not possibly to continue having a National Health Service run on only 8% of GDP (the lowest spend on healthcare of almost any OECD nation). We must also put to one side the recent publication by the King’s Fund, the independent think tank, that states quite clearly that the government are not investing anywhere near what they promised they would in the NHS. It also demonstrates that the NHS is not a bottomless pit, as some of the media would have us believe. Read it in more depth here:
(https://www.kingsfund.org.uk/topics/productivity-and-finance/nhs-myth-busters)
We know we need more funding. We know there is much negativity in the press about the crisis we are facing, we know about the recruitment issues and we know about the low morale of staff and high strain on the service.
Having put all of that to one side and accepting that the NHS remains a political football, currently being given a good kicking, we do need to have a sensible conversation. Whether we like it or not, as we look into the future, it is unsustainable for the health and social care system to have to allocate 1/5th of its budget as a direct result of our lifestyles, 1/10th of its budget on diabetes (the vast majority relating to type II, which is hugely preventable and reversible) or to double pay for beds in nursing homes and hospitals 
because of unnecessary admissions. So…..what are we to do? Simon Stevens, the head of the NHS will, this week give a major speech on the direction the health service and the progress of the Sustainability and Transformation Plans (STPs), of which there are 44 across England – they have little chance of success if we do not believe that we are all in this together.
It truly involves all of us! We, the people, together must face this problem head on. We do not have to turn on each other in a time of crisis, we can turn to each other and use our collective wisdom and gifts to find a way through. This does not have to mean doom and gloom. It could mean better community cohesion, a more positive way of working together across the system, organisations working collaboratively in a way that makes more sense for those who need help and all of us taking a bit more responsibility for our own health and wellbeing. We must learn to rebuild the very fabric of society, based on love and trust, de-professionalise the public and civic space (as per Cormac Russell) and reconnect as human beings who care for each other and want to have systems that serve our needs. This will be made possible through multiple, small and large conversations in which we take time to ask some really deep and important questions, holding the space through the process of frustration as we wrestle together for solutions that we can all work with.We don’t leave our brains and expertise at the door, but nor do we behave in archaic hierarchical ways or hide behind our name badges and lanyards. Here in Morecambe Bay we have started this very process, using a set of values from ‘the art of hosting and harvesting conversations that matter’ – here is a link to one of our conversations in Morecambe:
http://aohhealthandwellbeingmorecombe.weebly.com
Over the next two years, our team will be working with communities right around this Bay to ask and explore some important questions, such as these:
If we take each of those questions in turn (as we plan to do) and really talk together about how we make society and therefore our health and wellbeing better for everyone, rather than leaving it to others to make those decisions from on high for us, then I think we will achieve more than we could ever imagine possible. It is in discovering one another, in encountering the other that we can be transformed and find new ways forward together.
A people movement or social movement such as this will invigorate and create space for those within the systems not only to reconnect with our own humanity but enable us also to have braver conversations about how we can share our resources more effectively, work together more creatively and reimagine how we can provide the kind of health and social care that makes sense for the needs of the people we serve. We might not save £50 million, but we can’t continue with things as they are and if we talk and work together, we could make a really difference.
It’s time to do the impossible. It’s time to turn the tide.
In my last blog, I talked about the exponential potential of what could be possible if clinicians worked together in a more collaborative way. However, far more can be achieved if we work together in and with our communities to create a social movement together around being more healthy and well. I’ve talked previously about the “battle royale” that occurred between Béchamp and Pasteur over whether we should promote health or fight disease. The answer is, of course, that we need to do both, but the clinical community is not equipped with the resource or power to do it alone.
What we cannot accept, though, is our current apathy or malaise that some of the health 
crises we now face are too much for us to do anything about. We are in the midst of a battle, which we are currently losing and it is time to gird our loins for a turning of the tide. Here in Morecambe Bay, we have started a conversation, not just among the Clinical Community but with the wider population about how we might become the healthiest place in the UK. Yes, we mean this in a very holistic way, but there are also some specific foci we have so we can together reverse some of the appalling health statistics we are facing.
For too long, we have simply laid down and allowed exercise to be taken out of schools, whilst our kids consume a bath full of sugar every year. All the time our own work and eating habits have become significantly unhealthy. We have relied on expensive drugs to fix our problems, rather than tackling the root causes of our excesses. It has lead to 1 in every 5 pounds in the NHS being spent as a direct result of our lifestyles and 1 in 11 pounds being spent on diabetes. We say we value the NHS above anything else as a nation (maybe an issue in it’s own right…..) but we do not behave in ways that show this value to be true. We have not been brave enough to challenge the status quo and together make a wholesale change both about how we promote health and look to aggressively reverse it when things begin to go wrong.
I suggest that within a generation, if we wanted to, we could render Type 2 Diabetes a rare diagnosis. We can do this through encouraging far more healthy lifestyles in our children and young people now, like running a mile a day and learning to eat food that doesn’t actually harm them! I believe we could significantly reduce the need for so many people to be taking medication for hypertension and diabetes now, prevent many strokes and heart attacks, by being violent towards these conditions with major changes in lifestyle, though diet and exercise, rather than the prescription of drugs, using coaching, peer support and local champions to give psychological motivation and encouragement. We are beginning to have some excellent discussions and develop some exciting plans around this.
Our NHS health checks should serve as a major motivational opportunity for someone to
pull themselves back from the brink of a lifetime of medication and we should use all medication reviews as a chance to help people adopt lifestyles that might reverse the need for such drugs. In the process, we would also significantly reverse our number of cancer diagnoses – many of which are linked to our lifestyle choices. We simply can’t afford for our current and failing approach to continue. We need to be braver together! And this means the NHS must be willing to partner in new ways, not only with local people, but also with businesses like the major supermarkets to help reverse our current direction towards the abyss, in which there is no longer a healthcare system that serves the needs of everyone, no matter where they come from or how much they do or don’t earn.
Don’t get me wrong! We should absolutely use medication to its fullest use for those who are at risk and have not responded to major lifestyle changes. For example, we can wage war on Atrial Fibrillation, ensuring far more appropriate use of anticoagulation, in the most cost effective and safest way, therefore preventing many life-changing strokes in the mean time. And for those who, despite lifestyle measures, still have a high blood pressure or continue with diabetes, we should not withhold medication that would prevent major issues later on. It’s just at the moment, we’re reaching for the prescription pad too readily and not looking to reverse conditions completely before they set in. We need more education out there around the early signs of cancer, so we can hit it early and reverse it’s effects when we have a better chance. Respiratory disease is another area where we could seriously make a change. We need to think of ourselves as one big respiratory team, tackling smoking, housing damp and carpeting, whilst ensuring every person has an understanding of their condition, how to use their medication effectively and what to do when things flare up. A cohesive clinical community really could deliver something special in each of these disease areas.
We could also be a great deal more effective in how we care for the frail elderly. We don’t need anywhere near as many hospital beds. We can provide care in residential and nursing homes, avoiding double payment for beds, by shifting resource out of our acute hospitals and into the community. We need to have a far more grown up conversation about why we admit people to hospital when there is very little proven benefit of doing so.
Taking a strategic shift towards a social movement for health, significant lifestyle changes and treatment only after these things have been given serious attention, but unapologetically so once they have, we can turn back this battle at the gates and change the health of this nation for generations to come. We can undo the unaffordable situation we find ourselves in and discover together a much more healthy future.
We can absolutely do this!! It’s going to take some serious resolve and we’re going to have to withstand the fear and pressure of some pretty powerful lobbies, like the sugar, alcohol, tobacco and pharmaceutical giants, and perhaps even the government itself, but it is time for us to do the impossible. With love, hope and faith, we can do this! Yes we need to focus on schools and work places. Yes, we need to partner with organisations we’ve never worked with before. Yes, we need a far more effective media strategy and yes, we need to allow clinicians to work very differently. But we cannot do nothing. So let’s try something a whole lot more radical. That’s what we’re going for in Morecambe Bay – not just better care together, but better health together – you can watch and wait, and see if we sink or swim, or you can join us!
*Warning – this blog contains swear words (not that I’m usually a potty mouth!)
This last week we had a gathering of clinical leaders around Morecambe Bay – Nurses, Occupational Therapists, Health Visitors, Midwives, Doctors, Surgeons, Physiotherapists, Pharmacists etc. We were gathered from across primary and secondary care to look together at the financial deficit we are facing as a health community across the Bay where we are seeking to serve our population.
The debt we’re facing (a hole of around 38 million of our English pounds!) is no small thing. Most of it is historic and much of it had nothing to do with us. I spent my first eighteen months as a commissioner feeling furious at the government. I wanted to rail against the machine, the injustice of working in such an oppressive, top down and hierarchical system, which feels like being among the Hebrew Slaves in Egypt when they were told to make the same number of bricks with less resource available to them. I felt so angry with the fact that we invest so little of our GDP into health and social care compared to similar countries and when further unthought through policies were dictated from Whitehall, I felt a total rage. It doesn’t help being politically pretty far to the left and working under a regime to which I feel ideologically opposed.
But one day, I realised two things. The first thing I realised is that the government are not going to change their position or policy. Our systems of government are not set up in a relational, collaborative or solutions focussed way. It doesn’t have to like this, but this is the way it currently is. Our systems have become the very antithesis of their purpose. Rather than serve the needs of the people, the people now serve the systems. The second thing I realised was that my anger didn’t achieve anything except to make me feel tired, disempowered and stressed. I had retreated into the less healthy parts of my personality in which I was keeping false joy alive and feeling burnt out in the process.
Truth has the ability to set you free. When we face truth, no matter how painful, it gives the choice of being more free. Facing up to the truth that the government are not about to change their modus operandi and that I was feeling angry and stressed allowed me to step out of rather childish thought processes and step into something altogether more wholesome. It allowed me to step out of a false sense and rather oppressive noun of responsibility and gave me the space to think more creatively about how I am part of a community of people who can respond to the situation we find ourselves in. We can respond (verb) once we step out of the oppressive yolk of responsibility (noun).
So, those of us in clinical leadership may have not created the financial situation, but there are some stark realities for us to face up to. Whether we like it or not, our current ways of working carry much waste, caused partly by the way the finances of the system operate, but also because we have not thought of ourselves as one. There are ways we behave within the system that create more financial problems and do not serve the community as well as we could. And so it is time for us to do what we can, within our gift by being much braver in our approach. I am suggesting that there are three Cs that are vital to our future.
We need to reimagine ourselves as all being part of a team who are together tackling the health crises we are facing. We know only too well that, as just one example among many, we are failing kids with asthma because we have not joined up our resources or thinking adequately enough. Yes there are major issues with housing, smoking and pollution, but let’s not point the finger or push the problem somewhere else. Let’s use the phenomenal brains God has given us to pull the right people round the table and work out what we’re going to do about it. Let’s change the way we spend our time so that we’re in schools, we’re listening to our communities and we’re partnering together outside of our normal comfort zones to change the health of the generations to come. We know only too well, that if we don’t shift our focus towards population health and work more intentionally with our communities, doing things with them rather than too them, we will never win this battle. We’re not about playing political games. We are about working with our communities to create optimal health for every person no matter who they are or where they are from. We need to be braver, push the boat away from the shore we know and face the uncertain waters of working altogether differently. In my next blog I will explore some of the possible ways we could work differently.
2) Clinical
In order for the NHS to adapt and become sustainable for the future, we must not be afraid of clinical leadership. Our managers have a phenomenal set of skills, which we must draw on, but there is a trust we have amongst the communities we are embedded in that means they will trust us, if we engage with them properly that will allow us to turn this ship in a new direction. We must partner with our managerial colleagues, but be braver about the direction in which we know deep down we need to head in. We have gained so much expertise and trust and this is not a time to waste it or bury our heads. We must be braver and bolder in our vision of what we can really achieve together.
3) Community
As clinicians we must, as many have stated this week, build bridges not walls. There is far too much division, suspicion and competition amongst us. (Here comes the swearing)…..I was in a conversation with a consultant colleague recently and he was relaying to me that another consultant referred to GPs as a “bunch of Fuck Wits”. In a separate conversation, one of my GP colleagues referred to consultants as a “bunch of arrogant Shits”. These kind of attitudes pervade the NHS and have created a culture of dishonour, distrust and division. Honestly! We’re better than this. How are we going to create the new workforce of the future that works across our currently artificial boundaries if we don’t teach them basic respect? This week a patient came to see me because he was dismayed at having to have seen a nurse at the hospital after suffering a significant condition and wanted to check that I, as a doctor, was happy with what he had been told. I could have laughed it off, but I wanted to stand up for my nursing colleague, who actually has far more expertise in this area of medicine than I do. The advice he had been given was perfect and completely in line with the best guidance available. We must not be afraid to challenge attitudes that are antiquated and out of place. More than ever, we need a culture of honour. A culture of honour is one in which we believe the best of each other, speak well of each other and appreciate our brilliantly necessary but differing gifts and expertise. We need to work out how we work effectively together for the best of the people we serve. We need to connect with each other and rehumanise the system in which we work. When was the last time you met as a cross cultural or multidisciplinary team and simply told each other what you love and appreciate about each other and the work you do? If we can’t learn to be more relationally whole, we will continue to work in the midst of serious dysfunction and strife. Come on – amongst us we have some remarkable gifts of wisdom, healing and hope. Let’s build the kind of culture and community amongst us that stands shoulder to shoulder, changes the story in the media and speaks with one voice to the powers that we are about the a new way of working together through relationship not hierarchy and fear. What might we really achieve together? It is this kind of collaborative clinical community that can change the future of healthcare, not just in the UK, but right across the globe.
So, we start 2017 with General Practice “skating on thin ice”, the NHS as a whole “creaking on the edge” and major concerns over funding and waiting times. Why don’t we step outside of that rather repetitive and boring story, and find a new one together – one that resonates far more with the ancient paths we once knew?
The world is changing, and not in a good way. We are becoming more separated from each other, our organisations and systems dehumanise us and we are becoming less well. The story that the ‘benevolent hand’ of the free market will work everything together for good is exposed in it’s nakedness, like the Emperor’s new clothes. The fabric of our society is unwinding as we become more disconnected from our own sense of wellbeing, our communities and the land on which we live.
How do we recover a sense of wellbeing? Where will we find healing for our past, present and future? How can we expand our own vision of what it means to be well, focusing not only on our physical health, but also on our mental, spiritual, social and systemic health?
How might the General Practice community move from being a group of health heroes, who fix people when they are unwell, to letting go of that old and unsustainable paradigm, learning instead to co-host, with others, an environment in which a community can be healthy and well? It doesn’t mean doing away with skills that have been crafted, but using them to empower others to be partakers and not only recipients. What if GPs or ICCs (Integrated Care Communities) faced up to the fact that they don’t have all the answers, nor the resources, nor the power to fix the problems in their local populations? What if they allowed themselves to become more of a part of their community, rather than separate or slightly aloof from it? What might a co-operative model look like? If every patient owned a small share of the practice and it truly ‘belonged’ to the community, just how radically might things change, without the need for huge ‘take overs’ by local hospital trusts or private healthcare firms? If we are to find a new way forward, we must all be willing to let go of what we have known and the power which we hold. We have to let go of our need to chase the money and imagine that we are like the city of Detroit, declare ourselves bankrupt, financially and spiritually and then together, break down the walls that keep us separate and find our way together.
When we host spaces in which communities can come together, rather than trying to be the experts who know how to fix everything, we let go of our need to be the heroes and come into a space for shared learning. As I spend time with a community of people recovering from various addictions in Morecambe, I find I don’t have the tools to fix things. However, I do find, that together there is a huge heart for a better and more healed society for everyone, so that others do not need to find themselves in the grip of addiction. We need to know less and find more corporate wisdom. We need to share our gifts and find the beauty of reciprocity – that it is in the giving and receiving of one another that we find a way forward in positive peace.
The future of our health and wellbeing relies far more on our interconnectedness and our community than on the systems we have built. Our systems must give way to become subservient to the longing of our hearts rather than the task masters which drive how we organise ourselves and live out our lives. Co-operative community gives us an opportunity to live something much more radically loving and kind, in which people and the planet really matter. Today is epiphany! A day in which some people with real wisdom realized that God came as a baby, weak, helpless and in need of community for health, wellbeing and development. If God is and needs community, how on earth have we become so disconnected from that story and made our whole way of being about experts and empires? Here is an epiphany for 2017. If God did not come as an imperial expert, but in weakness and humility, we need to do the same, if we are to find any hope for the future. The system will not change from the top down, it’s too invested in the broken story to be able to do so. But we, the people, can together be cogs that turn in new ways and realign ourselves with a way of being that brings better and more holistic health for everybody, everywhere.
Here is another interesting blog, from a slightly different perspective about how community really is the future of medicine – well worth a read, when you can make space for a nice cuppa and some left over Christmas cake (good for your wellbeing)!
