Author: Andy

Adam Smith Was Wrong!

I have recently been at a brilliant gathering of people, down in Sussex, called ‘Sparks’. I always find it to be one of the more helpful imaginariums which I spend time at and love the diversity of the people who come. What follows is some learning I’ve taken from my good friend, Mark Sampson and his fabulous PhD thesis.

 

Adam Smith famously stated: “It is not from the benevolence of the butcher, the brewer, or the baker that we expect our dinner, but from their regard to their own interest.”

 

Like Mark, I disagree with him! I do not believe that self-interest is the basis for individual interaction and whatever we are told, the unrestrained free market is not benevolent!

 

We have allowed economic language not only to inform reality, but to create it. The language and vocabulary of economics is performative – it creates the world around us. Why would we think that self-interested economics will lead to goodness in society when we do not believe that in other parts of society or our own lives? It is not true of our relationships in our families nor in our friendships, so why do we allow a split mindset in how we think about work?

 

Some economists (Robertson and Summers) have argued that we should promote self-interest in policies and act out of this same motive in business, but altruism in other areas of our life, like our family and charitable work. This is ludicrous!

 

As Kate Raworth has so eloquently demonstrated, this current model of economics is dividing us, isolating us and slowly destroying us. It may, in some ways have gotten us to where we are, but it is neither capable nor kind enough to give us the future that will lead to a more connected and healed society and a more sustainable planet. Enlightenment thinking holds very little light for us now. And so, it is time to let it go, to lament its failure and discover together a new language and a more sustainable model for a reimagined future. Some of this requires exchanging the language of scarcity to one of abundance, renouncing the doctrine of growth for one of equilibrium, repenting of our obsession with competition and embracing relationship and collaboration and replacing self-interest with the notion of gift, reciprocity and mutuality.

 

This requires us to dig deeper into a spirituality and a paradigm shift in our thinking which embraces incongruity! The beauty of mutuality is that it recognises that there is personal benefit to the giver as well as the receiver in any gift-exchange interaction and it strengthens the bond of relationship. Since I watched the Christopher Robin movie, I’ve been thinking quite a bit about upsidedown triangles. Our current economies are built in pyramids, with those at the top “earning” and holding absolutely vast sums of money. What if we gave our most and prioritised those considered at the bottom as the most important? In the NHS we think a lot about ‘equality and diversity’ but often do little about it. For example, most of our waiting rooms and clinical environments are incredible unfriendly for people who have an autistic spectrum condition (ASC). What if, when designing these spaces, we didn’t tag on some kind of tick-box exercise afterwards to show we’ve considered people with ‘disability’ in a vague sense, but actually put them at the forefront of our thinking and planning? What if people living with ASC were at the very forefront of our planning decisions? Incongruous, perhaps, but a different kind of economy, which feels to me to be altogether kinder.

 

In my last blog, I explored how it is isolation (and competition caused by our need to try and overcome our human limitations) which cases poverty. What might we imagine together of an economy in which we prioritise relationships first, and worked together WITH those often left at the bottom of the pile or tagged on as an after thought? What might our planning cycles be like, if we slowed things down and really collaborated WITH our communities and truly considered all the benefits of mutuality? I believe we are at a moment in which the facades are well and truly down. We can see more clearly than ever just how broken our current economic system is, the true effects of putting our faith in the ‘free market’ to create a fair society and a sustainable planet and the realities of allowing our policies to be shaped on the notion of self-interest. It would be insane for us to continue with such a broken model, but it will take ongoing bravery to undo it’s myth in our minds, breakdown the strongholds of the many vested interests and to be part of a corporate reimagining of something based on mutuality and even incongruity!

 

In the end, I believe that when we deal with our root issues and become more healed, we are far more motivated by love than self-interest – and I see this every day! We are made in the image of God but allow ourselves to believe much less of ourselves. To quote Charles Eisenstein, “it is time for us to tell a more ancient and far more beautiful story which our hearts tell us is possible.” What if Milton Friedman was wrong and the business of business is not business? I know that may seem ridiculous, but what if the business of business is to ensure that every life matters, that we are more connected and living in a more sustainable way? What if it was the business of business to make real what really matters to us all? What else might a reimagined business of business be? And what effect might that have on how we think about economics and how we collaborate for a more mutually beneficial society and planet? I think we see this in many models and forms of business already. There are some wonderfully ethical and gentle businesses – I think this is especially true of smaller businesses where relationships are both vital and strong. It is the impersonal banking sector in particular, built on an economy of debt, with multi-lateral corporate giants that holds us prisoner.

 

The reason I am writing about this on this blog is that so much of our health and wellbeing is governed by our philosophy of economics and it is the language of economics which shapes so much of our thinking and reality. So, be careful how you speak about it, find some better words and let’s begin to shape a new future together for the sake of the wellbeing of humanity and the planet!

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Black Swans and Poverty

Here is a copy of the speech I recently gave at Morecambe Food Bank when Heidi Allen MP and Frank Field MP came to be with us and to listen to the community here in Morecambe Bay about our experiences of poverty. There were some incredibly moving testimonies from community commissioners of the poverty truth commission. This was my contribution:

 

“First of all I would like to start by saying thank you. Thank you to all of you for being here to talk about these really important issues. Thank you to my friends, Karen, Emily and Daniel for being brave enough to stand up today, to tell your stories and to allow yourselves to vulnerable and to be heard. Thank you to my friend Siobhan for being willing to speak out consistently about the realities that children in your school and this surrounding area are living with, and for doing so, despite unfair and untrue things being said about you in the public domain. Thank you to Annette and the team here at Morecambe Foodbank for your hospitality, generosity and welcome here today and for all the ways in which you provide for people in this community.

 

Thank you to Si Bellamy from the Eden Project – we’re so grateful for the hope that your partnership brings to this area and for the common values we share in wanting to uncover and deal with our deep systemic issues and injustices and co-create an economy and way of being as community that really works for humanity and the planet. Thank you to so many of our friends across the voluntary and public sectors for being here today and demonstrating our sense of unity in working together with our communities. And thank you Heidi Allen and Frank Field for choosing to work across your differences and to come and be with us today and to listen.

 

Today is not only about Morecambe. Morecambe is an amazing town full of wonderful people and there is a huge amount to be celebrated here. In fact, we could be having this same conversation, with similar but different and important communities across the water in Barrow, or over in Scarborough or down in Hastings because these same issues are found everywhere. Today is about coming together to really listen and to the reality of just how complex some of the issues we’re facing really are, like poverty, and the way it intertwines with many other aspects of our lives, for example our health and wellbeing.

 

Until 1791 people in England believed all swans were white. That was until a black swan arrived on these shores, brought here from Australia. Sometimes we can hold extremely fixed positions and ideas in our minds, until we are confronted by something which causes us to see the world differently. One of the truths about poverty is that it is an incredibly complex and wicked problem. And so it doesn’t help to entrench ourselves in our positions and throw stones at one another once those ideas are challenged.”

 

Robert Peston was right in his devastating analysis that we have become divided. So quickly we enter a blame game over poverty. “It’s your fault I’m poor”, “no, it’s your fault you’re poor”. But all this does is create more polarity, more distance between us as we become ever more entrenched in the certainty of our own arguments and perspectives. But that way of being is failing us, the 3 million children living in poverty and the hundreds and thousands of people who are now destitute. Trying to solve complex issues with overly simple questions is landing us in a mess! We want quick answers and we want to fix things but we do not appreciate the unintended violence of our policies and projects because we have not taken the time to listen, to understand or learn together. But when we do, we discover that not all swans are white and we begin to realise that we can longer continue to see the world that way.

 

The theologian, Samuel Wells, speaks of poverty as not being primarily about deficit, a concept that leads us into blame and heroism. Rather, he recognises that it is our dislocation, our isolation, our separation which is the real root cause of our issues. And so, here in Morecambe Bay, not only through the poverty truth commission, with the mantra that “nothing about me without me is for me”, but in many facets of our life together, including in the NHS, where I have the privilege of working both as a GP and as Director of Population Health that it is in togetherness, through relationship in which we are creating the space to build trust, to ask some really difficult questions and in the process we discover the reality of our pain and despair in one hand and in the other, as Barack Obama would say, we hold the audacity of hope, despite it all.

 

There are things to which together we are saying, “Enough now”. Enough now that some children in our communities cannot afford to eat, despite their parents being ‘back in work’ – and we are so grateful for the youth and community projects that open early to ensure kids get breakfast on the way to school and tea on the way home, despite a real struggle for resources. Enough now of the adverse childhood experiences or traumas through which many of our children our living, massively impacting their physical, mental and social health for years to come. Enough now of the reality that some children living in this Bay can expect to live at least 10 years less than children growing up just 6 miles down the road, with a far poorer quality of life along the way. And as we say enough now to those things and many more human and environmental injustices, we discover that the answers are not found in our current opposing political or economic models. Rather we are finding that together we can begin to create new possibilities of how we can re-imagine and build a future that works for every person and the planet.

 

In actual fact, learning to live well together is really difficult. It takes humility, forgiveness, kindness, breaking down hostility and replacing it with love. It means taking a good hard look at ourselves rather than pointing a finger of judgement at others. It means letting go of mechanistic thinking to fix things and embracing the reality of complex living systems. It means recognising that change starting with us. For me that means dealing with my own ego, my wounds, my root needs, my genealogy, my white male privilege, our colonial history and discovering that it is in encountering the ‘other’, someone utterly different to me that I am changed and I encounter in that person, the very face of God.

 

And so not only are we saying “enough now” to things which must change, but won’t change with our current ‘go to’ solutions, we are also finding that “together we can”. Here in Morecambe Bay, through working together as communities, we are seeing many dozens of initiatives emerging, like our food poverty project, our mental health cafes, community choirs and new partnerships forming across the voluntary, faith and public sectors working on issues like addiction and early intervention in neighbourhoods.

 

We are finding that together we can break down walls of division and find kinder ways of building society. Together we can see different perspectives and change our opinions and views. Together we can discover models of business based on mutuality and sustainability. Together we can help each other take more personal and corporate responsibility, whilst recognising how much easier that is for some than others and so together we can create compassionate communities.

 

Together we can face up to the challenges we see in our NHS and social care with the eye-watering savings we are being asked to make. Together we can ensure every child has a great start in life, we can build an education system that works for every child and face up to the growing mental health crisis in our young people.

 

Together we can ensure that our elderly citizens are respected and cared for. Together we can live in streets that are clean and safe, with every person having a warm, dry home to sleep in. Together we can face up to the environmental disasters which lie ahead if we don’t change. Together we can build a social movement for change with a different kind of power and discover a politics and economics that works for every person and the sustainability of the planet, based on self-giving, others-empowering love, empathy and kindness. And as we are here together today, together, through policy and through partnership we can ensure that no child goes hungry and every life matters. So, I am looking forward to listening and to learning together, through our conversations here today. Thank you.”

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Truth about Poverty

One of the best things I have been involved in over the last few years, is the Poverty Truth Commission and it has helped me to learn just how utterly complex and wicked poverty is as an issue. I’m currently reading an absolutely brilliant book by the theologian Samuel Wells, called ‘The Nazareth Manifesto’. In it, he makes the most accurate diagnosis of poverty that I have ever seen and it rings true of my work in clinical practice, my years of helping out in homeless projects in Manchester, my time spent in Sub-Saharan Africa, the poverty truth commission and my involvement in projects around food poverty.

 

Wells recognises the biggest issues in our society right now are caused by our massive obsession with mortality and our drive to overcome our human limitations. Using poverty as an example, he goes on to demonstrate that none of our current under-girding political or economic philosophies will get us even close to addressing the real issue. Our real issue is that we are isolated and dislocated and our breakdown in relationship leads to the deep sickness that we have in society right now. I don’t think I have ever seen this United Kingdom so utterly divided and truthfully, none of our current available options will bring us the unity we need to heal, forgive and find an altogether kinder and more sustainable future, together. It is our division which leads to the stark contrasts in life expectancy of people who live just six miles apart in Morecambe Bay. It is our dislocation that leads to such different life stories in Chelsea from the people who so tragically lost their lives in Grenfell. It is the disconnection between the City of London and Tower Hamlets that allows such gulf between the rich and poor.

 

When we look at the NHS 10 year plan, (apart from the fact that there isn’t the workforce around to deliver it and our local government budgets have been so utterly decimated that the gaping hole in public health and social care will ensure the plan fails), it is based on a defunct philosophy of needing to overcome our limitations. The NHS cannot save us from our current sickness of separation and isolation and nor can we expect it to.

 

Taking the example of poverty, Wells examines our current motifs for explaining this very complex issue and what it shows us about society. Poverty is currently explained through either Deficit or Dislocation. The ‘deficit metaphor’ can be illustrated in three ways:

  1. The desert narrative explains that people are poor because the do not have enough (of whatever) and so this can be ‘fixed’ by transferring resources. However, he shows this is deeply flawed as a parable because it dehumanises those who live in poverty, creating an ‘us and them’ mentality in which the rich/powerful try and fix the issue via ‘quasi-colonial’ approaches or use things like food aid to effectively control local populations in abusive ways.
  2. The defeat narrative focuses more on winners and losers and takes quite an unhealthy emphasis on the role of ‘personal responsiblity’ without really considering the other very complex factors like public policy and housing prices….
  3. The dragnet narrative is what the Millenium Development Goals are actually based on (see ‘The End of Poverty’ by Jeffrey Sachs) and considers poverty to be a dragnet/trap which makes it impossible for the poorest to even get onto the bottom rung of the ladder so people can climb out. It focuses on redistribution of wealth via 0.7% of GDP but is very paternalistic and is about doing to or working for, rather than a collaborative ‘together with’ approach.

The ‘dislocation metaphor’ likewise can be understood in triplicate:

1. The dungeon narrative explains poverty not as scarcity but as sin. It is either due to the sin of people who unjustly lock up the poor through their own greed and unfair policies. Or it is understood as the sin of people through making bad choices and therefore ending up trapped in their own prison. However, it still relies on external factors to fix it and so generally remains highly paternalistic.

2. The disease narrative explains poverty as a sickness which lives in our relationships, communities and societies. It recognises that, just like disease, poverty is extremely complex and multifactoral and so does not focus on apportioning blame.

3. The desolation narrative focusses on symptoms>causes, for example how the reality of poverty has a far greater effect globally on women than men – leading to major injustice, oppression and abuse of women across the globe.

 

Wells argues that the reality of poverty, whether local or global is primarily due to isolation and our obsession with mortality and overcoming human limitation is actually making our isolation even worse and therefore making us more sick. And for Wells, poverty is not fundamentally about the absence of money or the lack of conventional forms of power (although this is a part of it), but it is far more about the impoverishment, the industrialisation, the manipulation, the breakdown or the perversion of relationship. It is our isolation from one another that leads to exasperation, impatience, the pointing of fingers, blame and the villifation of ‘the other’. Just look at the polarisation on twitter between the right and left and the appalling name calling and slinging of mud and you see exactly what I mean.

 

The reality is that neither of our increasingly polarised political options is going to heal us or help us find a future that will be good for humanity or the planet. Our political ideologies are so opposed between liberty (right wing) and equality (left wing) but neither is equipped to help us break through this curse of isolation and find a new way forward together. I believe that we have reached a critical point in which we need to find an altogether kinder, more compassionate and collaborative politics and economics that is based first of all on humble listening and genuine democratic conversation to help us find a way forward together, rather than this current division and hatred. I believe as we find each other and build relationships (something which social media can so easily rob us of), we come to appreciate our different perspectives, learn from each other and find that we actually care about each other. I know, for sure, that by learning to BE WITH rather than DO TO or even WORK FOR has really changed how I see others and how I believe we can build a fairer and kinder society for everyone. It demands humility and forgiveness, based on a self-giving, others-empowering love as we build positive peace and requires of us, personal change and the dealing with our own self-centredness as we discover the beauty of connectedness to all people and all things. Theology shapes a great deal more of our philosophy and life together than many of us would care to accept! Well’s thesis is that the character of God is first and foremost discovered in these four words: ‘God is with us’. So often we think of people having a ‘God-complex’ who are people who think they know everything and do things to people because they know how to fix things. It smacks of arrogance. What if God isn’t like that at all? What if the most important thing to God is being with people? What if ‘being with’ is where it’s at and ‘doing to’ and ‘working for’ is to miss the point of what it means for us to be human and whole?

 

I wonder if we are brave enough to let go of that which is actually killing us and the planet and begin to find an altogether different way forward, together. Isolated, we die. Together we live.

 

 

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Health and Society

Every year I get to give a guest lecture at UCLAN medical school on health and society. Here is my lecture from this year – always a moving feast and next year it will be different. It’s about an hour long, so makes good as a podcast, if you’re interested! Mainly aimed at doctors in training, but I hope is interesting for all! I cover the wider issues like: why we’re currently losing, social determinants of health, poverty, choice and responsiblity, social movement, new power, humility, kindness and various other things! UCLAN is a new medical school and I love their approach to teaching. You’ll need to copy and paste the link below into a new browser to hear the lecture and view the slides.

 

https://vls.uclan.ac.uk/Play/34633

 

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A Fallow Year

This coming year of 2019, I am letting my garden have a rest – letting the ground be fallow. It gives space for the soil to replenish and to have its nutrients restored.

 

I am personally trying to allow much more space this year for contemplation, silence, reflection and the deeper work of stillness. I’ve sown a lot of seed over the last few years and now I need to take stock and see what is emerging, what is growing, what has life. There will probably be fewer blogs, though not necessarily, as I may use it to journal. There will definitely be less social media (starting with a complete 6 week hike from it form January 1st). I am so aware how often we focus on the activity, but do not do the deeper work needed in our lives.

 

As a Type 7 on the Enneagram, I know I can easily run away from pain – I am learning much more to sit with it. I know I can easily return to gluttony – not just for food, but for anything – new ideas, an idealised future, dreams, experiences……. I know that my natural defence mechanism is to rationalise everything, so that I don’t have to deal with the complexity of ‘feeling’ it! I know that I can so easily fill my time with so many fun and exciting adventures, always looking to the next possibility rather than sitting in the present and just being. Although, in many ways I feel more healed and more whole than ever, I am painfully aware how easily, I trap myself back in my ‘7 prison of escapist behaviours’ rather than living out my life more fully and freely, in the deep knowledge of being unconditionally loved.

 

I have personally found the enneagram such a useful tool, not to box me in, but to help me understand the box I am already living in and how to be free of it to become the best version of Andrew James Knox that I can be. I would say, in my clinics and in my leadership work in the NHS, that my greatest sadness is seeing people who never really do their ‘deep work’. They never really get to grips with their root issues, never really face up to their deep needs and resultant behaviours which leads to all kinds dis-ease. In fact, the world is run by such people and the effects for all of us and the planet, are devastating. If we are to embrace a kinder future, in which empathy, love and compassion can really come to the fore, then we have to be willing to do our deep work ourselves (from which no one is exempt), letting go of our anger, pride, deceit, envy, greed, fear, gluttony, lust or sloth in the process.

 

So.……what’s the deep work you need to do in 2019?

 

This year, my deep work is to embrace contemplation, to pause and reflect, to listen and to be present. I hope I learn more the secret of doing nothing. The Christopher Robbin Movie has given me much cause for thought (not least about inverted pyramids!).

 

After all, as one of my all time favourites, Winnie-the Pooh, reminds us:

“Doing Nothing Often Leads to The Very Best Something.”

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A Vision for Population Health and Wellbeing – All Together We Can

If you haven’t yet had the chance to read the Kings Fund’s vision for population health (and it’s the kind of thing that interests you) then I would heartily recommend that you do so. (https://www.kingsfund.org.uk/publications/vision-population-health). It is a real ‘Tour de Force’ and deserves some significant consideration. I like it because it doesn’t hold back from bringing some hard-hitting challenge, but also creates hope of what is possible. 

 

Last week, whilst I was in Hull, I unpacked some of my (many) thoughts about population health, drawing on the wisdom of this report, the significant challenges we face and the opportunity we have to reimagine the future, together with our communities. I was hoping to offer it as a podcast, but it didn’t record well! This is quite a long read, but I hope encapsulates the key issues and gives us plenty to wrestle with and discuss, reflecting on the great piece of work from the Kingsfund. 

 

When it comes to population health, we have to remember, especially when we look at a global stage, that the UK has had some of the best public health in the world. We have so much to be grateful for and have had some incredible breakthroughs in our health and wellbeing over the last 200 years. Consider how our life expectancy has increased, initially through the great improvements in clean water, sanitation and immunisations and then the emergence of the NHS, with free healthcare for all, no matter of ability to pay, and subsequent lifesaving interventions in the areas like hypertension and diabetes – we’ve come a long way, though there is still plenty of work to do! 

 

However, there is a lesson in humility that we need to take from the All Blacks (consistently the greatest sports team in the world). After successive world cups, which they should have won, they had to take a good, long and hard look at themselves and face up to this uncomfortable truth – they were losing! (and I imagine after the mighty victory of the Irish against them recently, they may be having the same conversation again). We have to face up to the fact that right now, in terms of population health, especially around health inequalities, we are losing and we’re losing BIG. 1 in 200 of us is currently homeless. Childhood poverty is increasing year on year and many of our children go hungry on a daily basis. According to the Food Foundation, our poorest 5th of households would have to spend 43% of their entire income to eat the government’s recommended ‘healthy diet’. Much of our housing stock is unfit to live in. Our healthy life expectancy gap between the rich and the poor is nearly 20 years, with a shocking difference between the North and the South. We have a mental health crisis in our young people, with suicide the leading cause of death by some mile in Males under 45. And to top it all, we have a severe shortage of staff in the NHS and our public services which make it actually impossible to continue the level of service required by the heavy target-driven culture of Whitehall. 

 

To continue trying to deliver the same services in the same way, when these issues are so starkly in front of us, is beyond insanity. We simply cannot continue to continue with business as usual and think that we will achieve anything different or new. This is why I like the 4 interlocking pillars the Kingsfund recommend when thinking about population health and I will unpack some thoughts about each one. 

 

The Wider Determinants of Health

 

Before I start on this section, it is really important for me to state that despite what others have at times accused me of, I am not actually a member of any political party and so when I write things which challenge current government policy or praxis I am not trying to score political points. In fact, I believe it is one of the key purposes of (health) leadership to call out when decision making processes are harming the health and wellbeing of the population (whether intentionally or not). Indeed, the same would apply, whoever was in (seeming) power. 

 

When it comes to tackling the issues of population health, dealing with health inequalities and ensuring that the health and wellbeing of all people and the planet is taken into account in every government policy, the current administration is found sorely wanting. No matter what is peddled out about the “successes” of Universal Credit (which I do actually believe was introduced with some good intentions), it is failing and will continue to fail as necessary safeguards are not being put in place. Since the introduction of UC, we have seen a staggering rise in the use of food banks. Families, especially children are going hungry and the financially poorest in our society are not having their basic nutritional needs met. Since 2010, we have seen childhood poverty rise and the health inequalities gap widen. Much of this is owing to the burden of austerity being carried primarily by our poorest communities. In this same time period, we have seen the loss of overall goals for population health and no clear directives or measures to encourage change. In fact, many of the more project and target driven approaches to population health are often the very things that cause a worsening of health inequalities, like child obesity initiatives, because they do not focus on the wider determinants of health like poverty, housing and planning. 

 

On one level, we should applaud Matt Hancock, Secretary of State for Health and Social Care for encouraging the NHS to get into the game of prevention. However, a mirror then needs holding back up to the government to examine what this really means. It is clear that the current ‘rise’ in funding for the NHS, won’t even enable business to continue as usual (and one might argue that’s a good thing, because we need to change business as usual – except for the fact that there is no letting up on the drivers and targets from the Department of Health that continue to maintain the current modus operandi). The £3.4 billion per year increase won’t even touch the hole in our acute hospital trusts, let alone account for the whopping >49% of total cuts from local government (more than £18 billion in total, with more to follow), who are absolutely instrumental in tackling the wider determinants of health and wellbeing. Public Health, which has always been so vital to the work of prevention has been decimated within local governments, who are struggling to keep their statuary services up and running. So, no, it’s not actually that straightforward for the NHS just to now take on the responsibility of prevention, as the social determinants and wider economic issues, including funding aspects, are an absolutely vital component of getting population health right and asking the NHS to do so, simply piles more pressure on an already stretched and burned out workforce. An ending of austerity and an appropriate level of funding is vital if we are to achieve population health, uncomfortable truth for the government, though this may be.

 

Our Choices, Behaviours and Lifestyles

 

There is a worrying rhetoric finding voice that ‘people should just make better choices and take more responsibility for themselves’, but this is simply far less possible for so many of our communities than others, as a direct result of policy decisions and economic models over which they have no power or control. 

 

One one level, no one would argue that each of us has at least some level of responsibility to make positive lifestyle choices, make good decisions about what we put into our bodies and how much exercise we do or don’t take. But we must remember that this is so much easier for vast swathes of our population than others. 

 

There is plenty of evidence though that helps the NHS think about where to focus when it comes to population health management – where we can make the most difference. These areas include: smoking, alcohol, high sugar intake, high blood pressure, atrial fibrillation, high cholesterol (currently hotly debated!), healthy weight and positive mental health. Remember though, Sandro Galea’s work on ubiquitous factors! It is possible to focus in on projects like these and make health inequalities worse! These things cannot be done in isolation, but must be part of a wider vision. The temptation will be for governments to focus on these narrow interventions and claim great statistical significance whilst still not dealing the root issues. 

 

It is in this that again, we need to see the government come up trumps. Targeted and smart taxation can have a massive impact on the choices we make – we know this through the massive breakthrough we’ve seen in smoking in recent years. The same now needs to be applied to the highly influential, powerful and dangerous sugar industry. A best next step, according to Professor Susan Jebb, from Oxford University, would be to put a substantial tax on biscuits and cakes. Like it or not, along with our carb obsession, these are our biggest downfall and if the government are actually serious about tackling our ‘obesity epidemic’ then they need to break any cosy ties with this industry and stop the nonsense about being too much of a nanny state. Public opinion, which apparently hates the nanny state, thinks the smoking intervention was fantastic and the benefit is clear. The role of government is to see what damages our health and work with us to help modify that behaviour. 

 

An Integrated Health and Care System

 

There are plenty of places around the country where we can now begin to see the potential and power of working together differently. In the UK, Wigan, with great leadership from the likes of Kate Ardern, tells a powerful story of how incredible things can happen when population health is owned by everyone and a social movement is born. Manchester, with its devolved budget, political stability and holistically embedded view of population health championed by the Mayor of the City, Andy Burnham is a fine example of how working together differently can really offer some exciting possibilities. He recently said this:

“As Secretary of State for Health, you can have a vision for health services. As Mayor of Greater Manchester, you can have a vision for people’s health. There is a world of difference between the two!”

 

In Morecambe Bay, as an integrated care partnership within the wider Lancashire and South Cumbria ICS, we have already found some huge benefits in working more closely together. It gives us an opportunity to find solutions to the wicked issues we face through collaboration and combined wisdom, rather than through competition and suspicion. 

 

The integration is important at the macro level (where decision making and budgeting occurs), as well as in the micro level in our neighbourhoods. Our Integrated Care Communities in Morecambe Bay are without doubt one the instrumental building blocks we have to reimagining how we can deliver care more effectively for our communities. In each of our 9 areas around the Bay we have teams involving GPs, the hospital trust, social workers, allied health professionals (physios, OTs), police, fire service, community nursing, community and voluntary teams, faith organisations, and councillors working together for the good of our local neighbourhoods. 

 

The Places and Communities we Live in and With

 

Place is hugely important and so is community. Isolation literally kills us. We have certainly found in Morecambe Bay, that choosing to work differently WITH our communities, rather than doing things to them is fundamental in being holistic when it comes to Population Health and Wellbeing. It has meant learning to take our lanyards from around our necks, getting out of our board rooms (where traditionally we take decisions on behalf of people) and embracing humility as we learn to listen to and partner with our communities. One book I have found really helpful, personally has been ‘The Nazareth Manifesto’ by Samuel Wells. He is considered by some to be the ‘greatest living theologian’, and I consider it to be of vital importance for us to think and engage with these issues of heath and wellbeing as widely as possible, including theology, philosophy, sociology and economics, to help challenge and inform the necessary mindset shifts which are needed. Wells writes that for him, the entire Christian story is encapsulated in these 4 words: “God is with us”. Whatever, you happen to believe about God, there is certainly a majority view that if there is a God, he tends to be quite aloof, distant, hierarchical, dominating, controlling and power-crazy, if not seriously vengeful at times – and interestingly, we often refer to some leader-types as having a ‘God complex’! But if God is not like that, but is primarily about being WITH people, not over them, working WITH them rather than doing things to them, that has huge implications on much of western thought and how we set up leadership and governmental institutions! 

 

Hilary Cottam’s book, Radical Help and Jeremy Heiman’s and Henry Timms’ insights in New Power are both vital reading in really engaging with this whole concept. We need to radically embrace the fundamental truth of relationship as an agent for good and change in our society. Our public services have become devoid of real and genuine relationships with our communities. 

 

Over the last 3 years as we have had many conversations around Morecambe Bay, being honest about the financial predicament we find ourselves in (needing to save £120m over the next 5 years, 1/5th of our total budget, whilst still meeting all our targets!) and listening to each other as we try and work out how we can be more healthy and well together, so many beautiful and amazing things have started. These include: mental health cafes, community choirs, the Morecambe Bay poverty truth commission, walking groups, the daily mile in our local schools, new ways of working between the police, council and local communities, the voluntary sector working differently together, dementia befriending, mental health courses in our schools, a new focus on adverse childhood experiences and many many more. 

 

So Where from Here?

 

I believe we find ourselves in an intersectional moment in which we can unlock a very different kind of future than the one we appear to be currently heading for. It is time for deeper listening and a reimagining of how we really might live in a way together that cedes health and wellbeing of humanity and the planet through everything we do. This means we can honour previous ways of doing things, recognising where some of them have been detrimental and contradictory to true population health, letting go of our insanity in the process and find a new, more healthy way forward. It is vital that we consider these four interactive pillars of population health and embed them into every facet of our life together in society. This means ownership and resulting policy change by the government with funding that actually works for the kind of integrated, living and flexible systems we need to co-create. We need communities to find new ways of being well together, take responsibility for our own lifestyles and behaviours, with compassion and kindness for whom this is less than easy.

 

From my perspective this would mean a reimagining of politics – a rediscovery of how we live well together – away from binary competition and white male privilege and towards collaborative inclusivity and equality, based on love, kindness and compassion aka “kenarchy” in which we renegotiate our relationship with power. It would mean a reimagining of economics – a recalibration away from transaction and a ‘use and abuse biopower’ towards a ‘doughnut economics’ in which we learn to live in the sweet spot of environmental sustainability and human justice and mercy. 

 

There are so many things that we have accepted and reports we have ignored. It is time for us to collectively say “enough now” to that which is dividing and killing us and hold together the reality of despair and hope in our communities, as we allow the reality to sink in that together WITH each other, we really can begin to find an altogether better future for us all and the planet. It won’t be easy and means there are many of our own personal ego structures, deep wounds and problematic behaviours that will need healing and changing along the way, but let’s open our eyes and allow new eye light to help us see the future which in our hearts we are longing for. 

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To Hull and Back

Last week I had the complete joy (except for the awfulness that is the M6 and M62!) of heading over to Hull to speak at a gathering of Public Health and Public Sector people from across Yorkshire, The Humber and The East Riding, called “Minding the Gap”, hosted by the amazing Ian Copley. In my next blog, I will give the podcast of what I said and written piece, for those who prefer that format, about Population Health and the realities we are currently facing.

 

However, I thought it just worth reflecting on a really interesting lecture I heard by Prof Franco Bianchini from Hull University (https://www.hull.ac.uk/work-with-us/research/institutes/culture-place-and-policy-institute/culture-place-and-policy-institute.aspx) on the impact of Hull being European City of Culture 2017. It was amazing to see this little video, presented by the excellent Director of Public Health, Julia Weldon (https://www.yhphnetwork.co.uk/about-us/julia-weldon/), and to hear of so many wonderful, creative, life-giving, community-building initiatives that happened all over the City and the beautiful stories of people celebrating the history and many facets of this place. 

 

The sense of wellbeing and happiness in the City increased significantly during that year (not much of a surprise) and the injection of finance into Hull gave opportunity for some creative regeneration and fantastic projects. Unfortunately, since 2017, the overall sense of Wellbeing and happiness has now fallen to below what it was in the years preceding Hull as the City of Culture. What a shame! And interestingly, if you study other Cities that host Olympics, Commonwealth Games, or have other similar initiatives, you see the same pattern over and over. The hype wanes, the carnival moves on and what is left?

 

There is so much we can learn from this, if we want to. Firstly, if we only plan for an event and do not think about it as an agent of transformation for the future, then we risk sowing huge promise and then once the event finishes, things just go back to being the same old, breeding disappointment and disillusionment. This must be taken into account in the planning. Becoming a City of Culture gives the opportunity for a City to come together, not only for an event, but to turn the future of the city, releasing dreams of what it can become. This requires much wider ownership and community conversations about keeping the momentum and building on it. Secondly, leaders across the city need to own the future and hold true to the principles, especially once the funding is withdrawn. It’s really sad that the vast majority of schools have not felt able to continue the great initiatives in the creative arts or sports, which began and were having a great effect on children and young people’s physical and mental health, due to the pressures they feel around delivery of the curriculum. Surely there was an opportunity to reimagine the whole realm of what education might look like in the City of Hull, aligned to the values of the City and its hope for the future?

 

In the Jewish tradition, at certain points along their journey from Egypt to Israel, the people would build an ‘Ebenezer’. It was a pile of stones to mark a certain point on their journey that would help them remember what was past and what they were looking forward to. It was more than a monument. It was a stake in the ground which called to memory where they had come from, what they had been through but also opened up an altogether different future. My hope for Hull, is that 2017 City of Culture becomes an Ebenezer for the city, something they can look back on and say – “that’s when things really began to change, that’s when we celebrated our past but began to build a new future together, a city that really works for everyone and the environment we live in!” I fear, however, that the opposite will be true….a temporary flash in the pan and then back to the same old, same old……

 

I hope with all my heart that it isn’t too late for Hull to regain this momentum and despite the lack of funding (although this begs whole new questions about devolution) for the city to take hold of the promise of what could be. I also really hope that Coventry (the city of my birth) really hears and learns from the lessons of Hull and begins now to think of being the City of Culture 2021 to springboard into a new future for the city, rather than have yet another event that feels good in the moment, but does not bring the transformation of the City that is so desperately needed. Now is the time for Coventry to dream and to think creatively about what this opportunity really might become. 

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Choice and Responsibility

There is growing rhetoric in the media and within the NHS that the public needs to make better choices and take more responsibility for their own health. Who wouldn’t agree with that? Surely, we are the ones who ultimately choose what goes into our bodies – we choose our sugar intake and decide how much exercise we take, don’t we?

 

Well, given Philip Alston’s damning report on the the state of poverty and human rights in the UK, perhaps we should think a bit more deeply about this!

 

When we say that people ‘just need to make better choices and take more responsibility for their own health’, we need to recognise that it is far easier for some people in our communities than for others. When you’re living in poverty and you would have to spend over 42% of your income to eat the government’s recommended healthy diet, your choice is reduced. When you live in an area in which there is a far greater number of high street take-aways, due to how licencing works in your town and you can fill the hungry belly of your child with a £1 sausage roll or bag of chips, and you don’t have a microwave, or you can’t pay the electric bill because you’re on a scandalously expensive meter – then your choice is reduced.

 

When the transport you reply on to get to the shops has been cut and your nearest shops don’t sell much fruit or veg, so you fill up on carbohydrates and sugars, which meet your hunger, but increase your risk of diabetes – your choice is reduced. When you suffered several adverse childhood experiences in your early years and have never been able to get healing for the trauma and continue to find comfort for your pain in the food that you eat – your choice is reduced.

 

When the products you buy are now filled with a much higher calorie load than they were 20 years ago, and hidden sugars you didn’t even realise you were eating – then your choice is reduced. When you are one of the ones ‘back at work’ (because let’s remember there are more people in work now than ever before), but you’re on a zero hours contract and so you’re working 2-3 jobs a day, just to pay the rent, let alone the bills and getting no breaks in which you can sit down to actually digest your food, let alone make healthy choices from the work canteen that doesn’t actually supply any healthy choices – then your choice is reduced. When you are scraping everything together to make sure you don’t fall into more debt, whilst you are sitting with a benefit sanction for something that really wasn’t your fault and you are using a food bank for your meals and so healthy options are not in abundance (and let’s not even go there with sanitary products and how utterly dehumanizing the tampon tax is) – then your choice is reduced. When you have been kicked out of school because a no-tolerance policy left you in isolation or no-compassion and then you’re a drug runner for a local gang, where you feel like you fit in, but in fact, they own you….then your choice is reduced.

 

Let’s be a little more kind, can we? Let’s stop stupidly over-simplistic comments like – people should just take more responsibility for themselves. This is actually pretty impossible for nearly 14 million people in the UK. I’m not saying there is no choice and nor am I saying that people have no responsibility. I’m simply reminding us that it is a great deal easier for some than others and we are seeing child poverty on the rise and the health inequality gap widen – this isn’t because people in poverty are making bad choices – they simply have far less choice available to them!

 

So what needs to change? Government policy around austerity and universal credit, licensing, pricing, advertising laws, a living wage, the way we work with communities rather than doing things to them, a total renewal of our education system and a bunch more kindness in society as a start.

 

 

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Obesity – Genetic or Environmental?

Obesity has become part of a serious blame culture. “Just eat less and exercise more”, seems to be the simplistic argument these days. Social media is full of ‘fat shaming’ and the public opinion has shifted much more towards it being people’s own fault if they are fat – “they should just make better choices and take more responsibility for themselves”. It makes sense right? People just need to be a whole lot less greedy and a whole lot more restrained…..Well – just for a minute, let’s suspend our judgements, put away our pointing fingers or indeed, our shame and let’s examine the evidence….and then maybe we can have a much better and kinder conversation about the obesity epidemic we’re in and what might need to change.

 

A few weeks ago, I listened to the excellent Prof Sandro Galea, Knox Professor of Epidemiology at Boston State University, give an excellent lecture on: “What Do Obesity, Opioids and Guns all Have in Common?” the answer: They are all really complex and hugely important! I am shamelessly going to use his slides from that lecture to explore the issue of obesity in this blog, which Sandro has kindly shared with me.

 


If we take any given population, let’s start by asking this question: What percentage of obesity is determined by genetics, compared to the environment? Go, on, give it a go – write a figure down, or make a mental note of what you currently presume!

 

 

 

 

In any give population, there will be a percentage of people who have a higher genetic risk of becoming obese. In the diagrams which follow, these, dark grey represents those with a high genetic risk.

 

 

 


 

There will be some people who will be obese, with or without a genetic risk. In the following diagrams, these people are represented in red/pink.

 

 


The environment is represented in green. everything that is not ‘genetic’ is considered to be environmental. This includes, air pollution, adverse childhood experiences, advertising, sugar in products, transportation, access to shops, types of shop available, family income, affordability of food, use of food banks, etc etc. The more green there is, the less healthy the environment represented.

 

So…….if we take a population with the same genetic risk factors and number of obese people, let’s see what happens to those people with a higher risk of becoming obese, when the environment is less than ideal, e.g. high stress, poor air quality, high index of deprivation, low educational opportunities, high unemployment, poor access to shops, poor transport links, high numbers of junk food outlets…….etc – here is the population in a poor environment and those with a genetic risk factor are marked with grey dots:

Look at what happens to the obesity rate in that population!! All of those with a genetic risk factor become obese! The odds are stacked against them, because their choices are significantly reduced!

But take the scenario, with the same population in an environment which is much more positive, where there is less sugar in foods, where there are more healthy opportunities for good eating and exercise, where there is no need for food banks because employment is high, jobs are well paid and the welfare state is functioning appropriately.

In this scenario – the odds are in favour of those genetically more likely to become obese – BIGTIME! Obesity rates are far less and overall the population is much more physically healthy. People who are genetically at risk of becoming obese have far less chance of actually becoming obese!

What was your answer to the percentage question at the start? It was a trick question! the worse your environment is, the more your genetics come into play! So, now there’s a complex argument about who is responsible for the environments in which we live and who creates an atmosphere of choice!

 

If we take the food industry to start with, just look at what has happened to the calorie intake of foods sold in fast food outlets over the last 20 years. If you want French Fries now, you’re eating triple the calories that you were 20 years ago, due to larger portion sizes – always upsold in McDonalds (and other like minded companies)!! TRIPLE the calories! Who’s fault is that?! A turkey sandwich, which some might consider a ‘healthy option’ is now packed with more than DOUBLE the calories that were in that same sandwich just 20 years ago! Do the maths! The way this has been allowed to happen is appalling. The government, so keen on not being a ‘nanny state’ have allowed a deregulated ‘nanny food industry’ to lovingly shove calories down our throats without most of us even realising! Prof Susan Jebb, one of the leading experts in this field, globally is really clear – if we taxed cakes and biscuits and made healthy food more affordable, we would be in half the mess we’re in.

 

The same is true of exercise, and so opportunities to exercise, created by culture and environment are really important:

If you look at how much the advertising industry is spending on obesogenic foods, or you examine where junk food cafes are placed (disproportionately higher in our most deprived communities); if you consider the profound effect of adverse childhood experiences on our eating habits or look at the affordability of health food for low income families, as shown by the food foundation, then you begin to see that this over simplistic argument that people ‘should just take more responsibility for their own health’ is total nonsense. We need to take an altogether more kind and considered view to what is an incredibly complex situation.

 

Sandro Galea talks powerfully about this principle: Small changes in ubiquitous causes may result in more substantial change in the health of populations than larger changes in rarer causes.

You can feed your goldfish the best food, ensure they swim their mile a day, help them practice mindfulness every morning and decrease the amount of time they spend on screens……but if you don’t care for the quality of the water – they will die!

 

Health inequality between the rich and poor in the UK is worsening. Health inequality between the north and south is worsening. Life expectancy overall and healthy life expectancy are both beginning to fall. Our mental health crisis is deepening. Now is not the time for loads more programmes that benefit the already healthy and make the inequalities even worse. Now is the time to ask some fundamentally deeper and more difficult questions about what we have built our society on, what the point of the government is and how, together, we might work for a future that is better for everyone. Unless we do so, the NHS continues to stare into an abyss, as indeed do all our public services.

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It’s Time to Say #EnoughNow to Adverse Childhood Experiences

Last week, I had the utter privilege of co-hosting a conference with my good friend, Siobhan Collingwood, the head teacher at Morecambe Bay Community Primary School on Adverse Childhood Experiences (ACEs), at the Globe Arena. We both know the reality of ACEs every day in our communities (see my previous blog) and so wanted to bring people together from across our amazing community in North Lancashire, working in the public  and community sector, or simply with a passion to see change, to explore how we can begin to say “Enough Now” to ACEs. (Huge thanks to the incredible Jon Dorsett for his graphic art).

 

As part of the day, my friends, Ian Cooper (Chief Inspector of Police) and Nick Howard (who leads the team at the city council on housing and planning) hosted a 135 minute conversation for all 180 participants around this theme: ‘Together, what can we do to transform the experience of childhood for good?’ There was such a buzz as people from different backgrounds and perspectives, collaborated and challenged each other to break out of our boxes and find new ways to bring transformation. The ideas generated were incredible and each person left the room with a clear commitment and next step for what they needed to do in their place of work or neighbourhood. Already we are hearing amazing stories and initiatives which are beginning as a result and we are building networks together.

 

We had fantastic input from Prof Warren Larkin, Sue Irwin (and her excellent work with EmBRACE), and host of other brilliant people working across many sectors, lending their expertise to further the conversations in interactive seminars – the feedback on each one has been incredible!

 

So – there is a huge challenge to the English Government (Scotland, Wales and Northern Ireland are already streaks ahead) as to why they are not taking the vast evidence base seriously and playing their part in breaking this devastating cycle. If we are to tackle this enormous issue of ACEs, it means vast changes to the ways we are delivering and measuring education in our schools and a serious reassessment of cuts of funding to children’s centres, midwives and health visitors, removing target-driven outcomes and finding ways to put relationship back into the heart of our modus operandi. It will take a people movement to bring the shifts that are needed, but given just how devastating ACEs are to physical, mental, emotional and social wellbeing and the huge cost burden they are to our public services and society, we have to give ourselves to drawing a line in the sand, saying enough now and reimagining the future together.

 

Here in Morecambe Bay, and across Lancashire, we are taking this issue really seriously and believe it to be one of THE most important population health issues of our time. A few of us have co-authored a ‘Little Book of ACEs’ together, in conjunction with Lancaster University – available very soon (!) which you might find helpful. My section expands a little on a previous blog post I have written here.

 

This whole area of ACEs is so sensitive, it takes compassion, kindness, bravery and wisdom. We cannot face it alone in silos, but together we can! Together, we can bring healing to our communities and freedom for the generations to come. We have to be willing to be those, who life Gandalf, in ‘The Lord of the Rings’ take our staff and say to this Balrog, which has devoured too many lives – “you shall not pass!” We have to give ourselves to drawing a line in the sand, saying “enough now” and step into a reimagined future of childhood, together.

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