How The Enneagram Can Help Us Be More Well

Over the last 18 years, I’ve been journeying with the help of the Enneagram – although I would say I’ve taken it more seriously over the last 6-8 years. I have found it to be utterly transformational in how I understand myself and how I can become my best self. I would recommend it to anyone and everyone – it is honestly the best tool I have ever found for personal/spiritual development, and how to live well in human relationships. The hard reality is this – if we don’t do our (inner) work, we will never change. I think it’s also true that understanding our own personality type and those of other people allows us to be much more focused in therapeutic and medical interventions. I hope this blog helps us to get to some of the root issues in our personality types that can cause us to sabotage ourselves then it comes to living well in our bodies.

Your Personality Type

I have personally found the Enneagram an incredibly helpful framework for understanding how the the human personality develops and why we behave and think in the ways that we do. The teaching is ancient and sacred and I am certainly no expert. There is absolutely no way that I can even begin to do justice to this wisdom in such a short blog, (although it is something I will continue to explore in future posts and podcasts), but I hope some of my personal reflections on what I am learning may be helpful by way of introduction. In short, the wisdom of the Enneagram teaches that there are 9 basic personality types or ‘ego-projections’. In response to encountering the environment around us as we grow, our personality develops around our deepest unmet needs and root struggles/’sins’. This is our ‘false-self’. If we are not awake to who we are and how we function in the world then we will not understand why we continue to behave in certain ways and trip up over the same issues again and again. The gift of the Enneagram is that it doesn’t define who we are are and what we will be. It helps explain why we’re stuck in the box we are in and helps us break out of it, so that we can be become more fully who we really are. Over time, as we develop and do our work, we are less obviously one number or another and begin to become more whole. The Enneagram invites us to surrender ourselves (to God, as Richard Rohr clarifies) and let go of the need to keep up the pretence of the ‘false-self’ we have created to protect us and/or impress others and instead to become our true selves and a true gift to others.

There are two main traditions within the Enneagram teaching. they have some similarities and some differences in their understanding and application of The Enneagram:

Enneagram Worldwide (which is what I know more of) and The Enneagram Institute. Their websites are great resources:

https://www.enneagramworldwide.com/

https://www.enneagraminstitute.com/

If you’re interested, I would recommend any of these following books:

The Enneagram Made Easy – Renee Baron & Elizabeth Wagele

The Road Back to You – Ian Morgan Cron & Suzanne Stabile

The Essential Enneagram – David N Daniels & Virginia Ann Price

The Enneagram – A Christian Perspective – Fr Richard Rohr & Andreas Ebert

The Wisdom of the Enneagram -Don Richard Riso & Russ Hudson

The Sacred Enneagram – Christopher L. Heuertz

The Enneagram of Belonging – Christopher L. Heuertz

If you prefer podcasts, these ones are helpful:

The Enneagram Journey with Suzanne Stabile

Typology with Ian Morgan Cron

If this is something you decide to explore I would REALLY recommend that you don’t take an online test. Read or listen to some stuff first – take notice of your responses to the various types. There will probably be two or three types that you might associate with, after you’ve got your head around some of the basics. Read/listen around those types first and THEN take a test or two, if you’re still not sure. I really like what Richard Rohr says when he mentions that the type that you most react to may well be the type that you are! Often it is uncomfortable for someone to hold a mirror up to us.

Let me just offer some brief insights on each type to whet your taste buds and see if this might be something that helps you, or alternatively, stop reading here and either buy the books or disengage with this idea completely! I am particularly grateful to my incredible Enneagram coach/therapist/friend/spiritual mentor, Paul Wood for helping me in my own understanding and growth.

Before we delve into the nine ‘types’, it’s worth saying a quick word about the three triads and the three sub-types!

Each of the Enneagram types is divided into groups of three. The head types: – fives, sixes and sevens; the heart types: – twos, threes and fours; and the body types: – eights, nines and ones. As a doctor, I am fascinated by disease and although I haven’t seen any research into this yet, I think it would a fascinating area of research to understand how the various types affect physical health conditions. There are definite links with certain mental health conditions and some personality types are more prone to develop certain ‘personality disorders’. Perhaps more on this another time!

The Enneagram also teaches that for each of the 9 personality types, there are wings and also 3 sub-types – social, sexual and self-preserving. For those of you who know the Enneagram, I’m not even going near the wings in this blog! The sub-types though, are pretty important because they can make people of the same type behave pretty differently.

Each of us has one dominant sub-type, one secondary sub-type and one ‘blind-spot’. One of these best ways to think about it is this: if you walk into a room full of people, with a buffet on one side of the room, what do you do (other than walk straight back out again – type 5!?!)? If you work the room and like to make lots of contact with people, you’re likely a social sub-type. If you make a beeline for the buffet whilst checking out where the exits are and ensuring you stand in a place where you will feel most safe, then you are likely a self-preserving sub-type. If you are trying to work out who the most interesting person in the room is, with whom you could have a really in depth and personal conversation, then you’re likely a sexual sub-type. I, for example, am a social sub-type, with a secondary sub-type of ‘sexual’ (or I prefer the term one-to-one), but my blind spot is ‘self-preservation’. What that means is that I love to have lots of company, go to lots of gatherings, usually where there is lots of food, with which I tend to overindulge (out of politeness, of course), and I have a great time working the room and can also get absorbed in some really interesting and deep conversations, but I can very easily forget to think about my own needs – so I over eat, rather than recognising when I’m full and I stay out late, when actually I could do with an early night etc. Needless to say, these sub-types have a huge bearing on how we respond within our individual types.

Type 1 – The Perfectionist/The Improver/The Reformer

As children, Type Ones tend to see the world as being pretty perfect and are ‘good children’. Their inner desire is to be able to play and enjoy life. But they begin to realise that life is not perfect. In fact the world is very imperfect, damaged, flawed and spoiled by all kinds of things over which they have no control. They have a need for things to be perfect. However, in their failed efforts to make happiness happen they develop a deep sense of anger (their root sin/stumbling stone) because their need is unmet. But they don’t want to project this to the rest of the world around them, because they are ‘good’. So they develop an ego projection to world that they are ‘reasonable’ – and this leads to rigid self-control. This then causes some pretty unhealthy behaviours, both for themselves and towards others, which are particularly hard to admit to and face up to. These include being self-absorbed, emotionally reactive, controlling, unhelpfully perfectionist, critical and actually deeply resentful of the world around them that isn’t the way it should be.

The invitation for all types is to face up to their deepest stumbling stones/sin and this is a really hard thing to do. It sounds brutal, but the invitation for the One is this: to admit that they are actually deeply rebellious and selfish. To stop their judging of others and to stop their unkind self-critique. If they do this, they make room in themselves for irrationality and messiness. When this happens it allows them walk into and receive the grace of an inherent sense of joy and lightness in simply ‘being’ and to find a real integrity between the inner experience and the outer expression. They come into a place of integration where they let go of the anger, so that it no longer controls them and find their inherent goodness allows them to experience life in its fullness and truth. When Ones step out of their ‘ego-structure’ and into ‘gift’ they become incredible leaders. They inspire and instil a sense of goodness. They make a difference in issues of social justice because they know that the world can and should be better than it is right now. They bring change to society through encouraging others to be their best selves and make fantastic coaches and communicators.

Type 2 – The Helper/The Giver/The Server

As children, Type Twos deeply long to connect to others. They would struggle to admit it, but at the root of their problems is the reality that they struggled to get the attention they craved or felt like they deserved. They lack a sense of inner peace that they are deeply and unconditionally loved. So, in a bid to get noticed, they develop a need to be needed by others and start to believe that people will not be able to cope without them, which leads to their stumbling stone/root sin of pride. This leads to the development of their ego projection to the world that they are loving and helpful people. To others it seems like they are reaching out and connecting, always giving of themselves. But deep down this is what the Two craves – the acknowledgement that they are kind, helpful and giving of themselves. But what is really happening (and it’s hard for two to face up to this) is a need to dominate and control others with this attention, which they need in order to fill their inner void.

The invitation for a two then, is to admit to the negative feelings they have towards others (and themselves) and to allow their own needs to be important and to be met. In doing this, twos discover and receive the grace that the are deeply and inherently loved and accepted. Not for what they do, not for how they help, but simply for who they are. This allows them to stop being shaped by their need and become truly loving out of a place of knowing that they, themselves, are loved. In their best selves, they become full of strength, vitality and bring a gift of true mercy. They bring deep comfort and empathy to the people and communities around them. They are incredible ‘servant leaders’, no longer worried about getting the attention themselves but able to pour out their love for others, knowing that they are filled from a different source altogether.

Type 3 – The Achiever/The Performer

As children, Type Threes realise that they are vulnerable and they begin to worry about what might happen to them, if people discovered what they were really like. So, through self-effort and self-creation, they become like a demi-god and create an ego projection to the world that they are outstanding. They develop the remarkable ability to play exactly the right part in whatever setting they encounter, because they have a deep need to be successful – but in doing so, they let go of their true self and so fall into their ‘sin’ of deceit. In fact, they can wear so many masks that it’s difficult for them to know their own true self. This leads to them seeking external validation to gain their sense of worth. However, what this leads to (over production, being over stressed, self-neglecting and disengaged from reality) is the exact opposite of what they crave.

The invitation for a Three therefore is to allow themselves to admit to their own anxiety and self-doubt. These self-made individuals are often racked with insecurity. When they stop and acknowledge this, they can relax into their own skin and stop needing to perform. For a three this is most often possible when they fail or when something happens which means they can’t perform for a while. When this happens, they can discover and receive the grace that being is enough – the place of true faith and they become grounded in belovedness. It doesn’t mean they stop achieving – it means that they learn to operate out of a sense of knowing who they truly are through an ‘internal’/deeper sense of affirmation, rather than the need for this to come externally. Healed Threes recognise failure as a gift. They are able to let go of the need to excel to win and become simply excellent! They make wonderful leaders and bring a sense of drive, and achievement to the teams they work in and with. Threes don’t just see the vision, they deliver it.

Type Four – The Romantic/The Individualist

As children, Type Fours have a sense of lack or real/perceived suffering. They carry a deep sense of being somehow tragically defective in some way and ‘cast out’ or like they are a misfit, who noone can quite understand and so they develop a kind of longing to be rescued. This creates a sense of comparison and others and leads them to their root sin/stumbling stone of ‘envy‘. So they create an ego projection to the world around them that they are sensitive, which pulls people towards them because they are ‘mysterious’ and feel things deeply. They have a need to be special. But this can lead to them being experienced as emotionally reactive and unpredictable. And this is used by the four (unconsciously) to control and manipulate relationships.

The invitation for the Four then is to admit to themselves and others that they are judgemental, envious and critical of others. They then have to risk letting go of their inner identity building in opposition to others and instead receive, in place of their felt sense of deficiency, the grace of an identity of ‘inherent and fundamental goodness’. This integrates with a sweetness and generosity of Spirit and allows the Four to bring an incredibly gift of beauty, artistry and creativity to the world around them. Fours make the world beautiful. They carry incredible creativity and wonder. They are incredibly emotionally perceptive and intelligent and pick up on ‘atmospheres’ and under currents. They are true empaths – sensitive, loving and at their best able to hold space for others to do their own work, without taking it on themselves.

Type 5 – The Observer/The Investigator

As children, Type Fives have a desire to assert themselves and take control of their world. But they find that the world fails to satisfy their inner emptiness. So they disengage and become more withdrawn (it’s quite rare though not impossible to be a Five AND an Extrovert!). Fives withdraw into their minds, because that is where it feels safe and they stumble over their root sin/stumbling stone of Avarice/Greed. This can be greed for ideas, but can be material accumulation also – Mr Microsoft is a classic Type Five. Fives develop a deep need to perceive. It is through their superior knowledge base that they can control their surroundings and gain an inner sense of superiority. So their ego-projection to the world is that they are perceptive and wise. This leads to some classic behavioural traits of withdrawing into their minds to ‘figure things out’. But this can lead to them being quite absent, distracted and have a hyperactivity of their mind – unable to ‘get out of their head’. One thing that can happen to a Five is that because they spend so much time in their head, they forget to listen to what their body needs because to them, what really matters is their mind, their thoughts, their ideas.

The invitation to a Five then is to admit to themselves and others that they use knowledge to dominate and undermine others. They then need to risk getting in touch with their heart and allow themselves to feel things more deeply. When they do this, they allow themselves to stop being so standoffish, to receive the grace of real self-confidence and find they can get involved in community and society rather than observing it from their ivory tower, firing sarcasm from a safe distance. When this happens they can also integrate with a deep sense of joy and lightness of being, bringing much more earthed wisdom and understanding into the world around them. Fives bring incredible wisdom and understanding to society. They are well read, able to dig deeply into complex ideas and make it available to the rest of us. Fives care about detail and this is important. They also bring a reality check with a sense of humility to problem solving.

Type 6 – The Loyal Sceptic/The Patriot/The Loyalist

Most Enneagram teachers believe that Type 6 is the most common Type – according to Richard Rohr, perhaps up to half the population might be Type Sixes. As children, sixes have a deep desire to be comfortable and for nothing to need to trouble or worry them. But they realise that the world is not altogether safe – it is random. This leads to a deep and existential sense of fear, which becomes their stumbling stone/root sin. As a result they develop an anxious alertness and believe in the idea of survival of the fittest. They therefore develop an ego projection which is that they are reliable, they are loyal and also sceptical. This leads to them seeking security externally. They can come across as true patriots – often looking for a leader who will make them feel safe – perhaps this is why in a time of uncertainty, political rhetoric around securing our borders and making our nation-states great again (Brexit/USA narrative) lands with so many voters. As a result of wanting to preserve this image of obedience and loyalty, Type-Sixes can easily become workaholic and expedient through are also quite image conscious because they worry a lot about what others think of them.

The invitation for a Six then is admit to themselves and others their deep need for security and comfort. Once they have done this, they need to risk quietening their minds, their anxious ruminations, their worries and their constant catastrophising of the future and instead learn to be still. When they do this, they will learn to receive the grace to be relaxed and trust in ‘Being’, knowing their inherent value. In this way and from this place of mindfulness, heartfulness and being present in the moment, they become truly loyal, faithful friends and can accomplish many great things with a sense of deep peace. Sixes make brilliant strategists. They see things very holistically. They consider the possible humps and hurdles on the road in front and are able to plan to mitigate these issues ahead of time. They ask good questions, see things from lots of different angles and perspectives and bring a much needed sense of realism to their work.

Type 7 – The Enthusiast/The Epicure

OK – full disclosure – this is my ego-structure!

As children, Sevens develop a sense of lack – that there might not be enough and feel overwhelmed by a build-up of issues. They respond to a sense that the world, or those around them have failed to make them feel content or safe. So, in search of ‘paradise lost’, they escape their sense of or fear of deprivation by drowning out any pain with pleasure. This leads to their root sin of gluttony – of food, or anything really – a false comfort, so they don’t have to face the reality of the pain they are feeling deep down. They develop a deep need to avoid pain, almost at any cost. So they project to the world that they are enthusiastic. Sevens can be huge fun to be around. However, much of this is ‘fake joy’ based in anticipatory energy of the next brilliant thing that’s about to happen rather than being present in the moment. As a result Sevens can become highly controlling of themselves and their environment in order to suppress the truth of what they are feeling. They want it to be fun! But this can be exhausting…..

The invitation for the Seven, therefore, is to admit to themselves and others that they really are overwhelmed and face the reality of the pain they are running away from. When they do this they recognise their deep dissatisfaction with life as it is and can learn the grace of contentment. When this happens they can receive the grace of discovering simplicity and a restored ability to focus. When they integrate this with a sense of things being OK just as they are without a constant need for more, then they can bring real, deep and lasting joy to the community and world around them. Sevens bring real deep, sober joy and gratitude to the world. They are enthusiastic and effusive, never lacking in vision or hope. Life is to be celebrated and Sevens love to party. They have an ability to assimilate lots of different perspectives and communicate in a way that galvanises people into action.

Type 8 – The Challenger/The Protector/The Leader

As children Eights have a deep desire to be held and loved, but they experience a real or perceived failure of others to love them as they need. This leads to them feeling let down. So they become determined to never be needy of dependent on anyone else ever again. They live to believe that they are in control and if they need something, they will get it for themselves. This causes them to stumble into their root sin of lust. Lust for power, lust for control, lust to dominate others. And so they project an ego to the world that they are strong. And as a result they have a need to be against. Against the expected status quo. Against the flow. Against the societal norms. This leads to assertive behaviours to demonstrate their strength and fierce ability to cope. But in doing so they become completely detached from their own needs. This can drive others away, and can be experienced as bullying – the exact opposite of what Eights actually crave, which is relational intimacy.

Difficult though it may be, the invitation for the Eight, therefore, is to let their guard down. To admit to themselves and others that they have weaknesses and unmet needs. And if they can risk openness or vulnerability with others then they will receive the grace of the experience of being truly loved. When they integrate this with deep clarity, insight and perception they bring true strength to the world and their desire for social justice, rather than burning them out, can come to the fore as a true gift. Healed eights make brilliant leaders. they look after their teams They carry a deep sense of social justice and they are not afraid to upset the apple cart to achieve this. They both challenge and inspire people to do the stuff that matters and live their best life.

Type 9 – The Peacemaker/The Mediator

As children, Nines have a sense that they want to be someone special and get noticed. However, they somehow come to believe that this will only happen if they make it happen by themselves. Not so keen on this idea, they fall over their stumbling stone or into their root sin of sloth or laziness. As a result, they become self-forgetting, zone out from the world, function on autopilot and tune out from the depths of life and project their ego onto the world that they are peaceful, easy-going and will fit in with anything. In so doing they lose themselves. But as they have developed a need to avoid, they don’t mind too much, as long as they feel comfortable. This leads to them becoming both anxious and passive, but when challenged can aggressively defend their comfort zone.

The invitation for the Nine, therefore is to admit to themselves and others that they actually do want and need attention. When they do this, they risk experiencing intensity and energy – but when they do it enables them to receive the grace to discover their inherent value. When they integrate this with real faith and courage, they can be present to the world around them and become true peacemakers and mediators – a much needed gift in our communities right now. When present to the world around them, Nines can bring incredible energy and purpose. They are able to hold the space for deeply uncomfortable and difficult discord and use their skill to bring reconciliation.

So many of our physical and mental health problems are amplified/worsened/affected by our personality traits. I hope these brief insights have been helpful and create a way of thinking about how your own personality might be affecting they way you view your won body, your own self-worth and how you are creating a story to the world about yourself that might need undoing. When we do our internal work and allow ourselves to admit how much it is actually costing us to keep on living in the way of the ego, we can learn to let go and receive the grace to become our true and best selves. Perhaps when we do this, some of our battles stop being about what we can control or what we are running away from and we can learn to live more presently in the world, awake to ourselves and able to make choices worthy of who we really are.

Poverty and Health Inequalities – What Can We Do?

Last week the Chief Medical Officer, Professor Chris Whitty, came up to Lancashire. He spent the morning in Blackpool and then came over to see us in Morecambe Bay for the afternoon. It was an absolute pleasure to meet him and to welcome him here. He came to listen – the mark a genuinely kind and caring leader. More importantly he came to listen to people who live in these Northern Coastal Communities, to really hear what life is like and to allow that to impact his thinking and he prepares to develop further strategy on tackling poverty and health inequalities. As an epidemiologist, he is grounded in data and understands the issues at hand. What I really valued was his humanity and humility as he listened to the stories of people who live and work here.

Last year, the Home Secretary, Pritti Patel also visited Morecambe Bay. She came to Barrow-in-Furness and spent some time at The Well, a CIC which works with people in recovery from addiction and of which I am a Director. In an interview afterwards, she was asked about the impact of Austerity and the reality of poverty in communities like ours (4 in 10 children in Barrow grow up in poverty). Her answer was that poverty is not the (sole) responsibility of government. I put sole in brackets, because she tried to insinuate that the role of central government in tackling poverty that exists in local areas is very minimal compared to the responsibility of local government (who have had their funding massively cut by central government in the last 10 years), local schools, local public services and local businesses. I’ve really wrestled with what she said since that time because she’s not altogether wrong! But nor is she right! Of course Central Government has a huge role to play in tackling poverty. It’s undeniable that national policy, economic strategy, including taxation, land ownership and business development all have massive implications. But poverty doesn’t only exist because of Central Government. Health Inequalities do not just exist because of Central Government. I am not for one minute, negating or diminishing their role, but we do have to all ask ourselves why we see and tolerate such inequality and what we can all do to change this narrative. Because as Michael Marmot reminds us so powerfully in his book ‘The Health Gap’ – none of this is inevitable and it certainly doesn’t have to continue. Marmot holds that “if you want to understand why health is distributed the way it is, you have to understand society.” So if we want to understand society, then as Prof Bev Skeggs (Professor of Sociology at Lancaster University) so eloquently says: “Society is shaped by our values and what we value“.

If we are serious about ‘levelling up’, ‘resetting’ and tackling age old health inequalities then we have to understand that this is both complex, but also entirely possible and need not take 100 years! As Marmot says in his amazing book ‘The Health Gap’ – essential reading for anyone who cares about this issue – we must do something and we must do it now! Marmot’s research proves that health inequalities are not a footnote to the health problems we face, they are the major health problem. We can actually make significant and measurable differences in a short space of time – so why aren’t we doing more? In the rest of this blog I hope to look at how we can make a real difference to poverty and health inequalities in our communities. We all have a part to play, no matter who we are. This is absolutely an issue for central and local government, but it is also an issue for society as a whole in all its facets.

Prof Imogen Tyler has written a phenomenal book called ‘Stigma: The Machinery of Inequality’. It is, in my opinion, the most important book published this year (I know that sounds like an overstatement, but it isn’t!). I believe this must be our starting point when we talk about poverty and health inequality. If we don’t understand how we have all subconsciously and/or overtly accepted a narrative that ‘the poor are feckless and lazy and could just pull themselves up by their boot straps if they wanted to, because we all have the same opportunities,’ then we are blind to the reality of the stigma that surrounds poverty and how it is weaponised to maintain the status quo. The thing is – it’s not just the government who have used this narrative – it’s part of British culture. So many of our comedy programmes ridicule and scapegoat the poorest in our society – The Harry Enfield Show (‘The Slobs’), and Little Britain (Vicky Pollard) to name just two. think of how many reality TV shows, like ‘Benefits Street’ have reinforced the stereotypes. Our national press continue to bombard us with very particular perspectives on ‘benefits scroungers‘ and ‘migrant swarms‘ and we read it, we drink it in, and whether we like it or not, it embeds itself as a way of thinking in our minds. That’s how propaganda works. It creates a corporate mindset by ‘othering’ our fellow human beings and pitting us against one another, rather than bringing us together to collaboratively find solutions in a way that works for everyone. It takes significant and sustained effort to do our own internal work around stigma, racism, white privilege, sexism and toxic masculinity. But if we want to build a society shaped by our values and what we really value then whoever we are – this is where we must begin. Our first work is to demolish the strongholds in our minds, challenge our unconscious biases and undo our ‘go to’ narratives, replacing them with deeper and better truths about the innate value in every human life. We must be determined to create the kind of language which reflects this because language gives substance to our thoughts and beliefs. This important work needs to weave its way through every part of our education system. This will take effect in shifting the corporate mindset through the way we teach history in our schools, for example, with a more honest appraisal of the negative effects of colonialism, or indeed how the feudal system continues to dominate the price of land and the unaffordability of good quality housing. We need to equip the rising generation with the tools they will need to undo the damaging ideologies of stigma and find solutions to the issues they are facing around social justice and climate change.

Imogen draws on the work of The Poverty Truth Commission, here in Morecambe Bay and in other places to highlight ways in which we can break down stigma, build friendships and create a kinder society. The Poverty Truth Commission gives us a real insight not only into how we break down stigma, but how the building of friendships across the dividing walls in our society creates a new political space from which we can create ‘the good life’ together. Our political systems have become far too removed from every day life and we need a radical shift from disengagement to much wider participation in community life and decision making. There are so many voices calling for this from all sides of the political spectrum. We so badly need to break out of our entrenched twitter-siloed positions and learn to curate the space for a more collaborative and co-operative form of political and economic conversation and prioritisation. It is, in my view, impossible to think about breaking down health inequalities without involving those who experience them most severely to be a part of finding the solutions. For further reading on this: Radical Help by Hilary Cottam, Rekindling Democracy by Cormac Russell and Greed is Dead: Politics After Individualism by Paul Collier and John Kay are all vital texts. This requires a much more local, devolved, participatory kind of politics – the kind of thing made possible through initiatives like ‘The Art of Hosting’, ‘Citizens Jurys’ and ‘People’s Assemblies’ underpinned by principles of love and kindness. In this way we can create much more realistic ‘deals’ (like the one in Wigan) between public sector organisations and people in our communities. This might all sound a bit wishy washy, but as Marmot demonstrates, “the lower people are in the socio-economic hierarchy, the less control people have over their lives.’ He argues that “tackling disempowerment is crucial for improving health and improving health equity” This is where the circular arguments about absolute or relative poverty are missing the point. When Philip Hammond stated as Chancellor of the Exchequer that he ‘doesn’t see poverty in the UK‘ – he was talking about absolute poverty and implying it isn’t an issue in the UK. He’s profoundly wrong. Economist Amartya Sen helps us understand this: “Relative inequality with respect to income translates into absolute inequality in capabilities: your freedom to be and do. It is not only how much money you have that matters for your health, but what you can do with what you have; which in turn, will be influenced by where you are.” Marmot argues that this means people in this position cannot participate in society with dignity. It is this active participation in ones own life and the life of the community around you, coupled with a sense that you can be part of the change that needs to happen which underpins the strap line for the poverty truth commission. “Nothing about us, without us, is for us.” If we want to tackle poverty and health inequalities in our society we have to radically include those who are currently most marginalised to be part of the change with us. We’re not trying to fix them. Together, we are trying to untangle the injustice that allows this kind of staggering inequality to continue.

The NHS is currently exploring its own role in tackling poverty and health inequalities. As the biggest employer in the country it has the opportunity to make a massive difference as an Anchor Institution, setting a good example and creating a network, both locally and nationally for other partners to collaborate with. Along with other local employers it can make a vast difference through positive employment schemes for people from poorer communities, paying a living wage, procuring locally and developing apprenticeship schemes, to name just a few ideas. We have developed a charter in Lancashire and South Cumbria, which we hope will be nationally available soon. I’ve previously written on the role of Primary Care Networks (PCNs) and how taking a ‘radical help’ approach with our communities could make a real difference at a local level. PCNs have a particular role in Population Health Management. This approach that we are focusing on across Lancashire and South Cumbria uses the best in data science and enables health teams to focus in on the areas of greatest need, working with those communities to bring about change through co-creation. If the NHS is really serious about ‘levelling up’, however, one thing which must be explored is the national funding formula. If we’re serious about Population Health, we must be much more comfortable with allocating resources according to Indices of Multiple Deprivation. We must also change what we measure and ensure that Key Performance Indicators and clinical funding streams are much more aligned to this entire agenda. Incentives do change behaviour and we need to make sure that we’re getting them right, whilst permissioning PCNs, in particular, to have a change in focus. We need to make it more attractive to work in areas of higher complexity and create more sustainable models of care. It is my belief that without a Health Inequalities lead at the top table of NHS England and Improvement, the right level of accountability and prioritisation simply won’t be there. It won’t be enough just to have someone accountable in each system, vital though this is. Integrated Care Systems must take an evidence-based approach and recognise what a profound difference they can make in a short space of time. The drivers in the system must be wedded to this way of working. The NHS must stop spending such a colossal amount of money tinkering around the edges of helping people to live a bit longer and get deep into the game of tackling the vast and ongoing health inequalities in our society. It must use it’s powerful voice to continually challenge policies which make this worse and actively campaign to make society more equitable. Marmot and The King’s Fund have already detailed so much that the NHS can do. Olivia Butterworth and Sara Bordoley and their teams are doing some great things. We need more of it! It’s time to act!

The issue of land and the lack of affordable housing has a huge effect on people being locked in cycles of poverty and creates massive health inequalities. Central Government has a huge role in sorting this out, but increased devolution may make it become easier with increased public participation in the daily politics of life. Most of the way our land is distributed and inflated was designed in the 11th Century and through the Middle Ages. Alistair Parvin has written the most phenomenal piece on this issue and it deserves time to be read and digested. He makes a very tight case as to why we find ourselves in the situation we are in, but encouragingly he comes up with some really possible, pragmatic and solutions-focused ideas about how we can solve this, if we want to. Of course there are many vested interested and people in positions of significant power, who would resist such an approach, but we must not let that stop us having some grown-up conversations about this. Parvin accepts that it would take a government with extraordinary vision and bravery to do what is really needed and offers some really helpful pragmatic smaller steps that would get us in the right direction.

I am not going to copy and paste his paper here, but I hope this whet’s your appetite enough to seriously engage in the possibilities. We can’t keep passing this ball to future generations. We have a once in a lifetime opportunity to reset our economy and in this time of ‘jubilee‘ we need to grasp this nettle if we are serious about creating a society that truly works for everyone. Mariana Mazzucato, Kate Raworth, Katherine Trebeck and Carlota Perez are just some of the brilliant people creating the kind of economic and technological frameworks we need. It’s time to build an economy of hope, shaped by our values and focusing on what we value. We know that the UK population would like us to place health and wellbeing at the heart of the UK economy instead of GDP – this is a massive shift and one that we must hold onto. This priority along with the creation of more social co-operatives, new local/community banks and credit unions would all help us to create a fairer economy that really works for the people.

So, we all have a role to play. As individuals, in our communities, through our work and via a more engaged, participatory, devolved, democracy, we need to deal with stigma and ‘wicked issues’, be determined to be more switched on, truly engaged and find together some pragmatic solutions fit for the 21st century. Disengagement is not an option. Let us not miss this moment. We can and we must do something. As Michael Marmot says in the final sentence of ‘The Health Gap’: “Do something. Do it more. Do it better.”

Taming the Chimp – Living our Values, Shaping Society

Prof Steve Peters, renowned psychiatrist, (particularly for his work with Sports teams) has written a brilliant book called ‘The Chimp Paradox’, which I regularly recommend to my patients. It’s well worth the read and full of helpful and practical tools to enable effective mindset and behaviour change. In it, he teaches about the 3 main parts of the brain when it comes to our habitual behaviours – what he calls The Chimp (Limbic System – where we make our immediate responses – based on our feelings and impressions), The Computer (the parietal cortex, which stores our automatic programmes and responses based on our beliefs and experiences) and The Human (the frontal cortex, where we do our thinking and make more conscious choices based on fact, truth and evidence, usually from a place of compassion and empathy). Many times we find ourselves acting in ways which are simply responses of our chimp brain – we’re not being guided by conscious choices or values, or even if we want to, we can’t seem to overcome the strength of our chimp. The problem is that our chimp is 5x faster than our human brain. And if we also have ingrained trauma-based responses to certain situations, when we are triggered (e.g. when we feel scared or lonely or whatever), our chimp gets ready to act, checks its facts with the computer which agrees that this is how it should/would usually respond and a bar of chocolate later……. Same old cycle, same old shame…..

So how can we change these patterns? Well, we need to feed our computer brain some new messages, so that when the chimp starts acting out and checks in with the computer, the computer no longer agrees with that old way of reacting, puts a pause on the chimp and allows the human brain to kick in with more positive choices. This happens, by consciously renewing your mind by feeding your mind your core truths and values. When you fill your mind with what you know to be true and the values you want to live by, you begin to make different choices. Your computer begins to store new and different information and therefore when your Chimp begins to act out, it will check in with your computer and find that the automatic affirmation of a learned behaviour can begin to change. This has huge implications in how we think about ‘taking responsibility’ and managing our own behavioural choices. I also think it has a wider application to our corporate mindsets and behaviours which cause us to continue acting in certain ways in society (which I will come onto later).

So, I have some core truths and core values which my lovely wife has painted on a board in my office. I have them written in my notebook, and (now less then I used to – to begin with it was at least twice a day) I remind myself of them regularly.

Here are the Truths that I live by:

1) I am unconditionally loved by the community of God (who unconditionally loves everyone and in whom we live, move and have our being), my wife and a bunch of other people

2) I am seen and accepted for who I am

3) Being a husband and a father are more important than any status I can ever achieve in work

4) It’s OK to make mistakes – in fact, failure is a gift

5) I can’t do everything – limits are important and so are teams!

6) Life is not always easy and happy, in fact it is unfair and really sucks at times – pain is part of the journey

7) People may not always deserve love and may not be easy to love, but you can still choose to love them – even your enemy

8) Forgiveness is a choice and it sets you and the other person free

Here are my Values:

Love people unconditionally

Walk with humility and integrity

Listen with kind eyes

Seek first to understand

Encourage and Forgive others and yourself

Act gently

Live generously with extravagant hospitality

Be open, honest and vulnerable

Leak joy

Release healing and hope

Walk in peace

Be faithful

Speak truth with compassion

Embrace pain

If you don’t know what is true and you don’t know what your values are, you cannot line up your behaviours to match them. If every time I experience pain, in whatever form that may take, I need to find comfort in a self-destructive behaviour, I have lost sight of my truths that I am unconditionally loved, that life sucks sometimes and have let go of my value to embrace pain. However, if I accept that I mess up sometimes. then I can forgive myself, and get back on track. It doesn’t have to mean a downwards slide. This is how change happens – slowly, but encouragingly as I learn to focus on who I am becoming, rather than believing I will never break out of unhelpful habits.

In her brilliant book, ‘The Value of Everything’ in which she talks about an Economics of Hope (how good is that?!), Mariana Mazzucato applies some of this thinking into the realm of how we build a society based on our values. What if we broke out of some of our self-defeating societal norms and built our economy from the best of our compassionate values? I wonder how many of our corporate chimp-computer agreed behaviours might change if we really examined what we value when it comes to the way we build society, through our economics and politics. So much of the time we are sleep walking with our eyes wide shut to the mindsets we unconsciously imbibe, which shape our corporate behaviours and choices. How often do we examine our core values or the truths that we live by? It takes determined effort to demolish strongholds set up in our minds and replace them with a renewed set of values with which we can build a more loving and kinder world. What would this mean for health inequalities, poverty, and who or what we might choose to prioritise? Without this work, however, we will continue to behave in ways which tolerate huge social injustice and climate destruction. But things do not have to remain as they are. We can change! Hold onto hope! In this apocalyptic moment, in which we are seeing the realities behind the facades more clearly than for many years, it remains time to rest, reflect, reimagine and reset.

Test and Trace – Time to Get it Right

Test and Trace is currently an absolute shambolic mess and there’s no point pretending otherwise. Over the weekend, a mum I know of in Morecambe was told to drive over 130 miles to have her children tested, only to find that the centre was shut when she got there! I know of another woman in Skipton (that’s in North Yorkshire, if you’re unsure), being sent to Northern Ireland! This cannot go on. It’s beyond ridiculous! It also massively undermines the idea of levelling up, because families who can’t afford to travel further then have to keep their children out of school for longer, causing further disadvantage to their learning opportunities. Imagine having a fever, feeling unwell and then being asked to drive a long distance to get a test, which should be available in your vicinity. It’s unsafe. It’s also unfair to blame people for booking tests unnecessarily when a) people are only able to get a test if the people employed by Serco allow them to have one, b) children can’t go back into school, once sent home until they are proven ‘negative’ and c) the Prime Minister has promised testing to pretty much everyone via his ‘Moonshot’ approach.

It’s vital, as we enter the winter months, to get this right. Our ability to provide safe staffing levels across the NHS and enable schools to function properly genuinely depends on it. Last week at the NHS Assembly we debated the issue and a possible way forward. The contract issued to Serco is clearly not delivering what is needed, and so it’s time to take an honest appraisal of where we are and how we’re going to fix this. I know the Assembly will be writing in an official capacity to Dido Harding, who is currently in charge of the programme. In the mean time, here are my thoughts about what needs to happen now.

It’s time to value the brilliant local public health leadership we have in place across the UK and ensure these leaders are supported to lead this work by providing timely data. After investing in the training and expertise of our Directors of Public Health, why on earth at a moment for which they have been trained to provide leadership are we circumnavigating them and making it so much harder for them to do their jobs? It would be worth an apology for not trusting them to do this in the first place and to own up that ‘Serco Test and Trace’ (not ‘NHS Test and Trace’) has failed in its task.
We must ensure that local councils and Directors of Public Health have the resources necessary to lead the local test and trace approach and ensure they have the necessary powers to intervene where needed.
The whole system must work – so we need to create more capacity in the laboratories across the UK to turn around results in a timely fashion.
It’s vital that we engage regularly with local communities of many different kinds and their leaders to ensure they understand where things are up to, how we can work together to keep people safe and debunk any myths that are developing, whilst holding space for the uncertainty of the moment.
Therefore we need clear, comprehensible messages to the public – we need to empower/permission local teams to lead on this messaging in a way that makes sense for their communities without constantly needing to check back with the centre. This comes down to trust.
The NHS and Local/National Government need to become much more comfortable with using different communication channels like WhatsApp – and for young people Instagram, YouTube and Tik Tok – because this is what young people are using now to the exclusion of nearly everything else…..if we have unclear messaging and then don’t even use the platforms that young people are using, we have no right to scapegoat them (which is terrible practice anyway!).
It’s really important that testing capacity is available rapidly and flexibly in areas with outbreaks. With the R number rising as it is and the current farce around availability of local tests, we simply can’t afford for this to continue.
We must recognise the value of and therefore ensure early intervention and action ,rather than delaying decisions. This has been highlighted by Sir Jeremy Farrar, CEO of The Wellcome Trust and member of SAGE in some current learning form Marseilles, where the hospitals are back at the point of saturation.

I’m not sure how or why it was decided that Serco should run this show in the first place. However it’s clearly not working. It’s time to make brave decisions. It’s time to get this local and focused. It’s time to get this right. Our lives may actually depend on it.

Why The Loss of Public Health England Really Matters

Yesterday, I tweeted that I think Dido Harding, the Chair of NHS Improvement and newly appointed head of the newly established National Institute for Public Protection (NIPP), which is to replace Public Health England (PHE), is a good leader. I say this, having met her and few times, through the NHS Assembly and her genuinely humble desire to listen and treat people with kindness. It caused quite an interesting discussion and there has been widespread criticism of her appointment.

Last week I did my yearly updates of the mandatory online training required in the NHS. Part of this included my ‘fraud awareness’ and this focuses, particularly on the Nolan principles – an ethical framework under which we are required to work. If these principles are not followed, people can quite rightly lose their jobs and even be sent to prison. The principles apply to all people who work in public life, not just the NHS and are as follows:

1. Selflessness

Holders of public office should take decisions solely in terms of the public interest.

2. Integrity

Holders of public office must avoid placing themselves under any obligation to people or organisations that might try inappropriately to influence them in their work. They should not act or take decisions in order to gain financial or other material benefits for themselves, their family, or their friends. They must declare and resolve any interests and relationships.

3. Objectivity

Holders of public office must act and take decisions impartially, fairly and on merit, using the best evidence and without discrimination or bias.

4. Accountability

Holders of public office are accountable for their decisions and actions to the public and must submit themselves to the scrutiny necessary to ensure this.

5. Openness

Holders of public office should act and take decisions in an open and transparent manner. Information should not be withheld from the public unless there are clear and lawful reasons for so doing.

6. Honesty

Holders of public office should be truthful.

7. Leadership

Holders of public office should exhibit these principles in their own behaviour. They should actively promote and robustly support the principles and be willing to challenge poor behaviour wherever it occurs.

The decision to disband Public Health England, (which is recognised internationally as a world leader in the realm of Public Health) and the appointment of Dido Harding into her new role (even though I do really like and respect her) are not aligned with the Nolan principles and I believe therefore that the Secretary of State for Health and Social Care, Matt Hancock has some serious questions to answer, which are absolutely in the public interest. Each of those questions should be framed around the Nolan principles and are a part of the accountability required in such a momentous decision. It’s not that Dido Harding (who called for more integrity in NHS leadership) is necessarily the wrong person (although many feel that she is). It’s the way the appointment was made that makes everything so murky and this is a great shame.

Public Health England must not be used as a scapegoat in the forthcoming independent enquiry into the UK’s response to Covid-19. We must also better understand where and how its other vital functions will be performed. As Jeanelle de Gruchy, President of the Association of Directors of Public Health, has so eloquently argued, the NHS is not currently set up to do this work. There is the potential that the newly established Integrated Care Systems (ICS’) across England, which bring together public sector partners, including the NHS and local government could hold the responsibility, but this would need to be funded adequately and appropriately AND would require a legal framework, which is currently lacking. We simply cannot afford to lose the vital functions of prevention, child health and other huge programmes previously co-ordinated by PHE. With further financial issues ahead for local government, the idea that public health prevention will remain a priority, when we have already seen the roll back of this since 2010 is unrealistic. If this happens, rather than ‘levelling up’, the great promise of the Prime-minister, Boris Johnson, we will see a worsening health inequality gap and those in our poorest communities struggling even more.

We need urgent answers to urgent questions. But more than this, we need a government who are willing to act with integrity, openness and through the proper mechanisms of parliament. Announcing major changes to the functions of public sector organisations through the press and the refusal to follow good processes in redesign are seriously unwise and unfair. Trust in this government is waning and they could do a great deal more to rebuild that trust, if they care to do so. The loss of Public Health England matters, not only because it does such incredibly important work beyond public protection, but because of the manner in which it was disbanded and what this means about how government is functioning.

When Matt Hancock made his speech about his new NIPP yesterday, he finished his Q&A session by talking about the “Holy Trinity” of Academia, Government and the Private Sector. I see very little that is holy about this triad, especially if the Nolan principles are flouted. The Trinity I know is full of love and truth…..I wonder what the consequences of this clear ideology will have on the future of the NHS. I fear the answer is not in the public interest.

Obesity (Part 2) – Let’s Talk About Trauma

In my last blog I looked at the complexity that surrounds the issue of obesity in our society. We have become far too focused on the individual and personal choice, whilst clouding the whole issue in shame and blame through stigmatisation. My hope is that we can talk about obesity with humility and compassion and re-frame the conversation from the all too often over-simplified position of ‘calories-in-calories-out’. Let’s be really clear as we begin to focus on what we can do as individuals, that we do not all start on a level playing field. We have different genetics, different sexes, different body types, different ethnicities, grew up in different environments, have differing belief systems and different personality types. We are different and this should be celebrated! So, this cannot be a game of comparisons. Tough though it may be for me to accept, I am never going to look like Joe Wicks! When I started to write this blog piece on how we might think about obesity as individuals and communities (given all the other complicated factors which make living well in an obesogenic environment so much harder), I thought that I would be able to write it fairly easily. However, I’m discovering that it could easily turn into a book! And so, I’m going to continue this a mini-series and write several more posts, partly so they are not too long and partly, so that I can explore the issues in more depth. The series does not aim to be the answer to every practical question about obesity, weight loss or positive body image, but I hope that it will be really helpful in setting out a way of thinking about the issues affecting us. I will look at some of the deeper causes and then some possible ways to find ways forward.

The Impact of Trauma and Adverse Childhood Experiences

I think we have to start here.

In the 1980s, Dr Vincent Felitti, Director of Preventative Medicine at the Kaiser Permanente Health System in San Diego, California, began to discover something troubling in his weight-loss clinics: there was a very high drop out rate and he couldn’t understand why. What we went on to discover, in conjunction with Dr Robert Anda, over the following 15 years was that around 50% of people in his clinics had suffered from a significant number of ‘Adverse Childhood Experiences’. Initially his patients would do well and lose weight and then stop attending and put their weight back on.Something I think we see again and again in the ‘diet world’.

Further studies across the USA and UK have shows that 50% of us have been through at least one ACE and around 10% of us have been through at least 4 of them. Trauma, especially in our early years, but actually at any time, can have a profound effect on our lives. The eminent Professor of Psychiatry, Bessel Van der Kolk, writes in his book ‘The Body Keeps The Score‘ about what changes take place in our brains, our genes and our subsequent coping mechanisms and behaviours as a result. The issue for many of us, who are ‘overweight’ is not that there is something wrong with us, but rather that something happened to us which has deeply impacted us ever since. My friend Lesley, an incredibly brave woman, whom I really admire, puts it this way:

“I wasn’t loved or nurtured as a child – I was abused. Sadistically. In every way. Although to the outside world we were a model family. I craved love and substituted it with food. I believe ACEs are a huge factor in obesity. In seeking comfort in food, I developed an emotional relationship with food. Rewards, celebrations, socialising, commiserating – we are all guilty of using food in these ways to a greater or lesser degree. Crack ACEs and I think we’d go a long way to tackling obesity and other ‘dependency’ type issues.“

(If you are familiar with this blog, you will know that I have blogged several times about what ACEs are and why they can have such a profound effect on our lives. There is also a link to a book I have co-authored on this subject here, – we have a new one coming out soon!). If you prefer podcasts, we have done one here.

For those of us who work in clinical settings, giving someone the chance to tell their story, rather than just referring them through to some new service or other can have a much more healing effect than we realise and might significantly change the next steps the person in front of us chooses to take on their journey. Giving a bit of extra time, to listen with kind eyes and to understand someone’s experiences can make all the difference in bringing real and lasting change.

Although not all of us who are overweight or obese have been through a terrible experience or trauma – it is true for many of us. Recognising the hard reality of trauma in our society and how rife it is, even within ‘model families’ helps us realise again the complex relationship we can develop with food and the resulting issues we can have with our weight. So firstly, let’s have some compassion in how we view ourselves and others, let’s not make assumptions about what people are like or what they may or may not have been through, because we don’t know their stories. Let’s also be committed to being trauma informed and a) help create the kind of society in which we see an end to as many ACEs as possible, whilst b) putting more protective factors in place to help children who are going through them and c) enable each other to get healed from the traumas we have experienced, without judgement. There are many things which can help us heal from trauma – the most important step is breaking the silence and the shame by telling someone we love and trust the truth about our story. Simply sharing the burden, being heard and validated is in and of itself deeply healing. Particular talking and psychological therapies like EMDR, family systems therapy and trauma-focused CBT are a helpful next step, alongside various physical therapies, which help us learn to live in our bodies without having to be defined by the traumas we have experienced. These can be available in certain NHS mental health teams, through various charities and private therapists.

Obesity (Part 1) – Breaking The Stigma, Finding The Solutions

Last week Boris Johnson declared that we must do more to tackle Obesity, as the evidence has shown that it is a significant risk factor in increased mortality from Covid-19. Why it has taken this Coronavirus to wake the government up, I’m not quite sure, when we’ve known about the risk from obesity in terms of Type 2 Diabetes, Cancer, Musculoskeletal and Cardiovascular Disease for a very long time. However, the new strategy the government have released, is welcome, although it still puts too much emphasis on individual choice and fails to grasp some of the most important issues.

I’ve blogged on here previously about the complex nature of Obesity in our society. If we’re really going to tackle the issue of Obesity, we have to break the stigma of ‘fat-shaming’, undo the myth that it’s really just a simple matter of people ‘taking more responsibility, eating less and exercising more’ (see previous blog in which I draw on the phenomenal work of Prof Sandro Galea), understand the vast machine at work which is actually making us all more unhealthy and work out how we dismantle it and promote much greater wellbeing across society. There is no shame in being overweight. If everybody were slim and lithe, it would be very boring. However, being overweight (as indeed I am, currently) does lead us to have increased current and future health issues. With so many of us (67% of men and 60% of women) being over our ‘ideal’ BMI (body mass index) it’s causing us to live with more associated complexities and we do need to face this, however difficult it may be. We are told that Obesity is reported to cost £5.1 billion a year to the NHS…..But what does this mean to anyone except to induce more shame that their choices are costing the NHS and they should therefore change….it’s unhelpful and deeply demotivating.

This conversation cannot be about blame. It’s about examining the root causes. There are multiple levels of responsibility and complicity and so the answers are not simple, but are multifactoral. What I seek to do in this two-part Long-Read blog post is look at some of the deeper issues and where we might move forward into genuine solutions. This means owning up to mistakes and failures whilst finding a way forward together. What I do believe is that those who hold power and make decisions must take a greater share of this burden, rather than pushing it down onto the individual. On that basis, this blog-post will focus on all the other levels that can affect obesity and the following post will look at what individuals and communities can do/change in the light of this. I am not trying to give all the answers here. But I am trying to give a bit more provocation to the depth of debate and hope that we might take this conversation seriously.

Let us begin with National Government.

The National Government (particularly since 2010) has been woefully deficient in this entire situation. I say that, as the Marmot report highlights how inequality and health outcomes have worsened since that time. It has hidden behind the rhetoric of ‘free choice’, stubbornly believing that the ‘benevolent hand of the market’ will cause things to balance out. This libertarian approach is based on the notion that ‘the Nanny State’ is too interventionist and it is not the role of government to tell people how to live their lives. The government have turned a blind eye to corporate greed and irresponsibility, whilst blaming individuals for making poor choices, part of the ‘stigma machine‘ it has driven over the past decade to paint a picture of our poorest communities. Yet last year the food and drinks industry spent £143 million on advertising obesogenic products to the British public! As Shoshana Zuboff so powerfully demonstrates in her seminal work ‘Surveillance Capitalism‘, there is very little ‘free choice’ left in the world these days!

Johnson is perhaps waking up to just how fed up the nation is with ‘Austerity’, but many still believe that it was a ‘necessary evil‘ to dig us out of an economic black hole. It was a political choice. One that was unnecessary and one that has done great harm to the nation as a whole, but in particular to our most deprived communities, particularly when it comes to health outcomes. Tory Peers this week have shown just how inadequate ‘Universal Credit’ is, we continue to see a rise in the use of food banks (where healthy food choices are not altogether plentiful), fast rising admissions to hospital for children with malnutrition, falling life expectancy for women in our poorest communities, and significantly worsening obesity, again worse in areas of greater ‘deprivation’. All the while, the government pushed the responsibility for fixing this mess, primarily onto the individual but also onto local governments, through the realignment of public health in the coalition government reorganisation of the NHS. However, devastating cuts to these localities, meant a significant drop in public health spending. We’ve seen the loss of sure start, exercise programmes and healthy eating help (something the government is now wanting to replace, through a new scheme involving GPs).

It has taken Marcus Rashford to wake the government up to the effects of child hunger, though the summer holidays and further reports have shown just how inadequate the funding of schools is when it comes to tackling malnutrition. It’s a strange conundrum that obesity and malnutrition actually go together in our poorest communities. It’s all well and good telling individuals to get out and exercise, but with the loss of 21000 police officers, communities are now less safe, with many young children and teenagers unable to access local parks due to the associated increase in violent crime and gang crime, also linked with the loss of youth centres. Where are people supposed to exercise? In Morecambe Bay, a staggeringly high percentage of children in Barrow, have never visited the Lake District or even the beach! The same applies to Morecambe and Lancaster. Perhaps there is a solution, which I will come to later, but all this finger wagging, whilst cutting genuine accessibility due to poor transport networks, shows just how out of touch the government are with the effects of their own policies. Cutting theses services in the first place has made the health inequality gap widen.

On top of this, there has been almost no effective regulation of the sugar industry, which continues to pump more terrible calories into our food, without even telling us (and labelling hasn’t really helped, due to the ongoing power of advertising, BOGOFs and product placement). It’s important the government sorts out its own policies in this arena and its current proposals are not good enough, although they are at least a start in the right direction.

So, what does the government need to do?

1) It needs to ensure that Universal Credit actually works or consider a Universal Basic Income in its place. Poverty and Obesity are tightly aligned and current provision to tackle both is entirely inadequate. Until we see the demise of food banks, we will struggle to tackle the basics of health inequality. However, on current predictions, years of failed policies for our poorest communities will mean this will only increase as we enter a deep recession due to the double whammy of covid-19 and brexit.

2) It needs to stop the game of stigmatisation and the false blame of individuals. In her seminal work, ‘Stigma: The Machinery of Inequality’ (which I think is critical reading right now), Prof Imogen Tyler looks at how Stigma is weaponised by governments to inflict policies such as ‘Austerity’. These same mechanisms have been used when it comes to obesity and this kind of shaming must end.

3) It needs to get a grip of the Food (and in-particular Sugar) Industry. It needs to set tighter boundaries around advertising (good to see the beginnings of this in the new strategy), product placement and the content of sugar in products and stop hiding behind the nonsense of the nanny-state (again good to see a start on this by changing rules around advertising before the watershed). The Kingsfund (great work from David Buck) has clearly shown that people did not mind the intervention on smoking and would actually favour more government intervention in this field. The role of government, we are told, is to protect it’s people. There is so much more to do than the initial proposals being made.

4) The government needs to raise taxes on particular products, especially cakes and biscuits, to support nationwide behaviour change. Without this, it will be difficult to tackle ingrained behaviour. A century ago, chocolate was considered a luxury. We need to think of treats as exactly that and not a daily snack and price changes will cause this to happen better than almost anything else.

5) The government needs to put necessary protections in place for the Farming Industry and create legislation that moves us towards a more plant based diet, that is better for the human biome and tackles climate change, whilst also helping us to have healthier and more sustainable diets.

6) This may sound utterly controversial, but I believe may be a solution to help tackle both climate change and our health issues: they should consider rationing. We haven’t seen anything like this since WW2, but we’re in unprecedented times. If we are to ensure that everyone has enough and all people can eat well (therefore diminishing the need for food banks), whilst also helping us learn how to do so in a way that is not overindulgent, then this may be difficult but necessary medicine. How can we live in a world in which we throw away so much food, whilst millions go hungry? Would rationing help us to discipline ourselves and find a more sustainable and equitable future available to all? Heavy handed, I know, and probably laughable in some quarters, but maybe, during this pandemic, we should at least consider it – giving everyone a universal basic diet – I suppose it would be a bit like exploring a universal basic income – something which is gaining more support.

7) Central government must adequately fund local government, in particular public heath programmes and schools. The leader of Lancashire County Council has been clear with the Prime Minister, that the new allocation is well below what is needed for the task ahead. Does BJ have ears to listen? Do the government really understand the true power and nature of local governments and what they can achieve in partnership with the communities they serve? Look at what the Marmot Cities are beginning to achieve. Do we really want to stifle this? The healthy lifestyle programmes must be adequately funded and appropriately targeted towards areas with the greatest problems. They must also be designed in a way that encourages health rather than shaming ‘unhealth’.

8) The Government must take on the corporate giants. A few years ago, I started working with the Consumer Goods Forum (a network of manufacturers and retailers, with a combined global turnover over several trillion dollars) around how they might work more seriously in partnership with the NHS and PHE around the issue of obesity, diabetes and health inequality. I have to say that to date, although there is lots of willingness on paper, a combined effort is hampered by competition laws and the primary motivation of profit over all else. They could easily change product placement, especially at the tills; they could easily have been more on the front foot in helping us fight this crisis. Instead, they have tinkered around the edges, whilst raking in the profits. I hope now that they see just what obesity is causing in the complexities around Covid-19 that they might just finally take this a little bit more seriously and play their full part in changing this narrative. They say that they are simply meeting the demands of the public, and yet they are the ones who have spent colossal sums of money in advertising to convince us to buy products that do us harm and then pricing and placing them in a way that makes them utterly irresistible. I am therefore highly doubtful that they will change their behaviour unless forced to do so, which is why the government must be more interventional. Some of these companies don’t even pay their fair share of taxes, taking the profits whilst leaving the NHS to pick up the bill.

What Is the Role of Local Government?

I agree with Geoff Driver that the current promised funding for Local Government is terribly insufficient for the task ahead. However, with whatever package is finally agreed, there are certain things which I believe local councils must focus on. Firstly, they must take a collaborative approach WITH the communities they serve, building with and on community assets. Secondly, they must get a grip of local licensing of fast food restaurants and take-always – the current government proposals are unlikely to make much impact in inner city areas. Thirdly, they must invest in green and active transport, taking this opportunity to create many more cycle lanes and safe walking paths to ensure that they tackle both climate change and obesity in the same move. Finally, they must replace services they have cut and work in partnership with local NHS teams, especially primary care networks on the delivery of proven interventions.

The NHS

Some might think the NHS has quite a lot on its plate currently, but there is no doubt that it has an important role in tackling obesity. GPs and Practice Nurses have proven through great work around smoking, that they can make a significant difference as part of an overall strategy. However, given the complex nature of obesity, my recommendations would be as follows:

1) We need to talk much more about creating a trauma-informed approach. I would like to see the opening of ‘trauma-recovery centres’ in each of the regions of England and the other 3 nations. The reality is that obesity is massively linked to adversity experienced in childhood/adulthood and coping mechanisms associated with this. We need to stop asking people, ‘what is wrong with you?’ and be far more interested to find out ‘what happened to you?’ or ‘what is your story?’. Compassionate communities are those that recognise the complexity of our human lives and look at people with kind eyes, rather than judgement. It’s vital that this is more true than ever in the consultations room.

2) Leading on from this, we need to widen the use of ‘motivational interviewing’ and ‘coaching’ techniques, with help of the ‘patient activation measure’. We are using this with great effect in Morecambe Bay – it works with people so much more effectively than just telling them what to do. It enables people to feel empowered to make the changes they want to see in a way and a timescale that is realistic for them.

3) We must stop funding national programmes, which are ineffective (many of which are a total waste of time and money, in my opinion), and instead invest in helping PCNs listen to the actual needs of their community, through initiatives like the poverty truth commission, and then partner with those communities to bring about real, lasting, relational and effective change. If you compare what local PCN programmes are achieving around Type 2 diabetes reversal compared to the National Diabetes Prevention Programme (NDPP), which the government have given a further committment to rolling out, you would scrap the NDPP and invest far more in local communities, which are much cheaper and significantly more effective. Local relationships and expertise trump nationally driven campaigns every day of the week.

4) We have to look at the GP model and provision of care in our economically poorest communities. It has to be more attractive and we need to be braver at putting funding where it is needed the most. We won’t break down health inequalities, if we don’t get more clinicians working in and with those who are struggling the most.

5) We need to encourage better partnerships between GP practices and local schools in working towards a healthier place-based curriculum. We’re very blessed in Morecambe Bay to be working on this with the fabulous Eden Project North, but not everyone has this on their doorstep…..so what is possible in each locality?

6) Hospitals need to be doing much more with the money they are already given in making sure that ‘pre-hab’, prior to surgery is far more effective. I am aware of hospital trusts in which high percentages of patients are having routine knee and hip replacements, and routine abdominal surgery (like hernia repairs and cholecystectomies – gallbladder removals) with very high BMIs. Not only is this actually unsafe, it leads to much longer stays in hospital afterwards, driving up the overall cost the procedures. If hospital teams were dedicated to helping people achieve optimal weight before surgery, the number of people actually needing that surgery would dramatically reduce. We are currently implementing such a model in Morecambe Bay, thanks to a great partnership between GPs, Surgeons, Managers and Commissioners.

7) We need to see a faster integration of PCN teams to include Health Visitors and possibly, community midwives. The first 1000 days of a child’s life are vital at determining the course of the the rest of it’s long term wellbeing. Working with the ‘maternal commons’ and changing the tide for the future generations is vital. Things like Breast Feeding (which can reduce obesity by 25%!) and healthy snacks need to become the norm in all our communities.

Employers Have a Key Role!

The work place environment is often incredibly unhealthy. However, we have learned together, through this current pandemic, that it really is possible for us to work differently. Greater workplace flexibility to encourage exercise breaks, healthy eating in the work place and active travel should now become routine parts of the day. It makes total economic sense. A happy and healthy workforce are more likely to stick with a company and have less time off sick. It’s absolutely vital that we end ‘in-work poverty’ by seeing a true living wage across the UK. It’s one of the reasons I am so passionate about seeing the NHS as an anchor institution in each area through the UK, partnering with other organisations to set the standard of good employment. The new NHS people plan sets us firmly in the right direction.

National Parks/The National Trust/Areas of Outstanding Natural Beauty

I would love to see an agreement between the department for education, local governments and these national treasures to become much more widely available to children from our poorest communities. These places are primarily now the playgrounds of the middle-class only, but this is unacceptable. How can we ensure that all our children can enjoy the delights of the counties across the UK, and not just the privileged few? How can we make it more affordable for communities to get to these places, pay the entrance fee (where warranted) or believe that they are really for them? The National Trust was set up for the poor…..can it rediscover what it exists for?

Schools

Schools are underfunded and teachers are underpaid – let me just put that out there, before making any recommendations. The amount that teachers are now having to deal with in their classrooms around hunger alone, is beyond unacceptable. Children in our poorest communities are eating highly processed and insufficiently nutritious food, leaving them both overweight and malnourished simultaneously. We desperately need to build a curriculum around food security and physical and mental wellbeing. The focus is currently wrong and we are punishing children who are too hungry to learn. We must also think creatively about the timetabling of Physical Education, especially for our young women. The link between maternal obesity and the child’s future poor cardiovascular health is staggering. I recently did some listening with some teenage young women, who told me plainly about the jeering they continually get from boys when in their PE outfits, the horrors of having PE in the first period and then feeling red and hot and sweaty all day and therefore the high numbers of ‘drop-outs’ from PE lessons. Exercise is such a vital part of life, helps us focus on our work and have better mental health outcomes. Given the crisis we are facing, both around mental and physical wellbeing in our schools, is it time to radically rethink the school uniform, the PE ‘offer’ and how we might move towards a more inclusive and less ‘macho’ PE culture? Alongside this, we need to look at the quality of school meals – surely we can do better?!

Conclusion

The current narrative around obesity is full of stigmatisation and is grossly oversimplified. I hope that this blog has highlighted some of the complexity involved and therefore why we should approach the discussion with more humility and compassion. Of course individual people and communities have a role to play in the choices they make and the behaviours they adopt (and in my next blog, I will give more thought and focus to this), but for too long, we have made that the focus and forgotten about the enormous environmental factors which have caused the situation we find ourselves in. We will have to see just how serious the government is about really addressing the health inequalities in our nation. Obesity is a good ‘test-case’ and will mean a major sea change in policy and implementation at every level of society. I hope this blog goes some way to stimulating even more debate about how we break the stigma of obesity and find solutions which genuinely change the outcomes for Marmot 2030!

The Future NHS and Care System – PCNs as Building Blocks

I recently wrote a blog about reimagining health and care in this apocalyptic moment. In this post, I want to put a bit more flesh on the bones of what that might actually look in the context of the NHS, here in the UK and particularly, England.

Let me just make a few statements about where I’m at when thinking about future health and care:

I believe in a publicly funded and provided national health and care service, paid for through fair taxation.

I believe that health and care should be available to all people, equally, regardless of ability to pay.

I believe in locally led health and care systems, embedded in local communities.

I believe prevention is better than cure and we need to get up stream and stop people falling in the river in the first place.

I believe creating great working cultures enables teams to flourish and brings out the best in people. I know right now that our health and care workforce is feeling burnt out and overwhelmed. We can’t keep working under the huge burdens of constantly changing goal posts, key performance indicators and heavily mandated targets. The wellbeing of those who work in this sector has been overlooked for too long and the stress levels caused by the sheer pace and volume of work are not acceptable.

I believe there is systemic and ingrained racism in our communities and within the NHS and even though I consider myself to be ‘woke’ about this, as a privileged, white, male, there is still so much work for me and us to do, both internally and externally in order to break the curse of white supremacy. It is simply not enough to say ‘black lives matter’ – our words are cheap unless we do not confront internalised narratives and change society together, from the inside-out through truth and action.

I believe our economic system is no longer fit for the 21st century and am so grateful for the reimagining of what economics is for.

I believe the role of government needs to radically change to be much more empowering of local communities, with appropriate frameworks to support this. We are seeing the mess of centralised control, with unchecked and wasteful investment in the private sector, rather than local community empowerment in this current Covid-19 pandemic.

I believe communities are able to self-organise phenomenally well, as we have seen throughout this pandemic and should be supported to do so more through a much more participatory and relational politics.

I believe that any health and care service should promote overall wellbeing by paying extra special attention to:

instating women fully and equally
prioritising children
advocating for the poor and breaking down health inequalities especially through challenging stigma (Very grateful to Imogen Tyler for her great work on this)
welcoming ‘strangers’ (by this I particularly mean the way we treat staff from overseas and how we care for refugees and asylum seekers)
reintegrating humanity with the environment (e.g. by getting back to basics of nutrition and sustainable food)
restoring justice to prisoners (metaphorical and real)
healing the sick – through both slow and fast medicine
ensure the honouring the elderly In how they are cared for

So……(!)……How do we take the best thinking around health and care systems and make it real and practicable in the NHS and Care System? Firstly, I suggest that we need to take the hierarchical, pyramidal system and simply flip it upside down. Let’s begin at the local level, as the foundations stones of a reimagined health and care system and build from there. With this we need to take seriously what Simon Parker is calling for in a rethink of what government exists for.

Within the health and care system though, we don’t another fresh reorganisation. We have some good things we can play around with. We just need to stretch our thinking a bit more and permission some creative, entrepreneurial experiments and we can see something really exciting emerge. Primary Care Networks are a good basic building block, which take the best of clinical leadership, and when done properly, combine it with local communities to build local health and wellbeing. They cause General Practice to work together more collaboratively, use the best of available data to map the issues a population are facing and have the flexibility to begin working differently. They are not perfect, and in my opinion, need some adaptation, if they are going to enable the tackling of health inequalities, social injustice and true community empowerment.

Firstly, they need more time. The phrase ‘at pace and scale’, used all too often in various management discussions In the health sector, is the antithesis of what the NHS needs right now. PCNs need time to build stronger relationships with their local communities, really listen to what their community are experiencing and build local solutions WITH their communities through co-design and co-creation. The constant onslaught of new targets, new measurement tools, new initiatives, all to be delivered by, well, yesterday, are completely counterproductive to the transition and revolution that community medicine needs to make. The current work load in General Practice is unsafe and unsustainable and is a byproduct of the consumerist attitude we have taken towards healthcare as a commodity. PCNs need time and will fail otherwise! This must be created for them.

Secondly, PCNs need to look at alternative and more sustainable models for the future. Currently, PCNs are very much built around General Practice at the core, and this makes alot of sense in many ways. However, here in Morecambe Bay, we have a building block called ‘Integrated Care Communities’ (ICCs), which pre-date PCNs by some five years. I believe we need to see a melding of the best bits of both, with a much wider and more integrated team within and around the PCN model. The traditional GP partnership model, though highly successful and desirable in so many ways, continues to build a model with the GP, primarily as the leader. I am a GP Partner myself – there are some huge benefits to such a model, especially often through great altruism and genuine community care. One of the difficulties facing primary care, as it stands though, is that few ‘future GPs’ want to become partners, preferring a ‘salaried’ approach and the issues facing primary care may, perhaps require a different kind of (and perhaps more socially just) economic model. I suggest that PCNs may want to explore the highly effective and entrepreneurial model of Social Cooperatives. Such models have proved highly successful in places like The Netherlands and New Zealand, provide greater sustainability, better collaborative working and more exciting opportunities. Drawing on the work of the economists, Spencer Thompson, Kate Raworth, Mariana Mazzucato, Katherine Trebeck (and others) I can see that a social co-operative model of PCNs, given trust and freedom to experiment, by either government or commissioners, could really remodel health and care at a local level, around genuine community need, as set out by Hilary Cottam in Radical Help. We could see the creation of locally led (and owned) community health and care services (perhaps even including care homes, who are still very poorly treated as we have seen through this crisis), creating healthy communities from pre-conception to death through asset based community development and participatory, democratic processes. A social cooperative model allows all people working together in a geography to be part of the same ‘system‘, rather than the current clumsiness of multiple ‘sovereign organisations’ tripping over each other, whilst creating similar community roles, bespoke to each employer’s whim. However, a cooperative model may not work for all organisations, like the police and fire-service (I’m happy to be convinced otherwise) and so building relationships, sharing milk and working having regular check-ins and multidisciplinary team meetings will continue to be important.

The possibilities at the local level are endless. PCNs would be able to prioritise a much more proactive, preventative model of health and care, employing smaller but more relational and therefore more effective and sustainable teams, embedded in local communities. They would form fantastic partnerships with local schools, co-designing a curriculum that creates positive mental and physical health, connecting young people more into their community and environment whilst being trauma-informed and compassionate in their leadership. Midwives, health visitors, social workers, community Paediatricians and mental health practitioners could form part of the core team and all work from the same geographical space with IT systems that actually talk to each other. Community care of the elderly would be more joined up, with care of the elderly physicians leading their own care of nursing home patients, supported by specialist nurse practitioners, along with, of course the incredible 3rd sector. It might be that some consultants, e.g. Rheumatologists, Dermatologists and Psychiatrists could belong to a cohort of PCNs, even employed by them, and therefore create a greater sense of belonging to a particular set of communities and they would also be able to work with communities more proactively through workshops, group consultations and education settings. Teams could flex and grow to suit the needs of a community, with the economic model set up to enable rather than constrain the flourishing of such initiatives. The social cooperatives could also form community land trusts which could begin to tackle various wider social determinants of poor health, including issues like housing, homelessness and access to green spaces. These cooperatives could ensure a living wage and persuade local businesses to get more involved in the area of health and wellbeing and even invest in the kind of initiatives that would create work in the green sector for local people. Why shouldn’t local health communities be involved in social change, when these issues affect the health of their communities so vastly?

I see local leadership teams (what we call Integrated Care Partnerships or ICPs), made up of PCN Directors, Local Government Officials, CVFS CEOs, The Police, Fire Service and Hospital Chiefs continuing to take the role of looking at a wider Population, made up of a group of PCNs and support them in tackling health inequalities, taking a servant leadership approach to empower them to succeed as much as possible. Primarily this group would be about permissioning, enabling, encouraging, holding space for learning and development, holding true to values and using data to facilitate excellence in practice. Relationships and trust will be the core ‘operating framework’ to enable PCNs to fully flourish.

The Integrated Care System (ICS) Leaders then need to take a similar approach with each ICP in their domain, giving as much power away as possible and taking a collaborative approach across a wider geography to learn from each other and encourage best practice and through the sharing of stories and success. It’s this kind of nurturing and facilitative leadership that will enable each ICP and PCN to flourish. Hospitals will naturally become more focused on acute care, and areas, like Oncolgy, as consultants become more aligned to the PCNs with which they primarily work (obviously this does not apply to all specialities, which is why an ICS can take more of an overall look at the hospital requirements for the population it serves). The role of the national NHS England and NHS Improvement teams then becomes the servant of all, the enabler and the holder of core values. Rather than a central command and control structure, it gives itself to a love-poured out model, creating cultures of joy right through the health and care system. Yes, it sets some priorities, but does so by listening to what communities around the nation are saying. So right now that would include asking PCNs to prioritise tackling systemic and ingrained racism, health inequalities and childhood trauma, in collaboration with their communities. They will take the best of international experience and learning, share that widely and reimagine the NHS as global trend-setter for how we create deep peace and wellbeing in our communities, enabling us to become good ancestors of the future. A radical, revolutionary but entirely practical refocusing of the NHS and Care System from the bottom-up is entirely possible. There is almost no remodelling needed, simply a change in focus and culture. It requires PCNs and the communities they serve to get on an do it together, disregarding that which prevents them. If they do this, they will find that everything they need will follow them and their light will shine brightly.

Should The Schools Go Back on June 1st?

Is the decision to send some of our children back to school on June 1st the right one? What are the factors that have been considered and how has the decision been made? I”ve been asked these questions a number of times and they bother me at several levels. They bother me as a Dad (and believe me I have an even deeper respect for teachers and the magic they do every day!), as a GP, as a School Governor of a Primary School, as a Trustee of a Multi-Academy Trust, as a Co-Author of a book about Adverse Childhood Experiences and as a local leader in the NHS as Director of Population Health in Morecambe Bay. So, I come to the questions with several different hats on and feeling conflicted in how I think about the issues involved. To be absolutely clear, this blog is written from a personal perspective and I am not writing in any of my official capacities, as with any blog on this site. I was having a conversation the other day with a friend of mine, who spent years working as a solicitor. We were talking about judicial reviews and the probity of any given decision. The vital test is this: has everything been taken into account that should have been; has anything been taken into account that shouldn’t have been? In other words, it’s not about the decision but about HOW the decision is arrived at. If the test is satisfied, it’s a good decision.

Firstly, I want to focus on the process of decision making. Over the last few years, working with the Poverty Truth Commission and using the ‘Art of Hosting’ as a framework for how to encourage wider participation, I have been greatly impacted in how I think about this process. In the PTC we follow the basic principle that ‘no decision about me, without me, is for me’. When the government made the decision to open schools more widely on June 1st, did they talk to the unions first? Did they discuss the ideas, concerns and expectations of many teachers prior to their announcement? Was there any discussion with children or young people about what they might feel about returning to school and what their priorities might be? Was there even an announcement to the house of commons so that the idea could be debated and discussed before deciding on the June 1st date? I think the answer to each of those questions is ‘no’. So, in terms of probity, it seems impossible to say this is a good decision without having taken into account such vital opinions and voices. I absolutely recognise that being in government at such a time is no easy task. If the government, here in the UK, continue to act without involving wider participation and conversation, it is less likely, especially at a time of such national anxiety and uncertainty, that they will be able to take the public with them. We need the government to choose to be listening, inclusive and honest about the complexity of the issues involved. If they do this, they will find national collaboration much easier to achieve.

Secondly, we keep being told by the government that we are being “guided by the science”. This statement alone poses so many questions! When Sir Jeremy Farrar, (watch from 10:30) CEO of The Wellcome Trust, and member of SAGE was humble enough to admit last week that it was a mistake not to have been far more on the front foot with testing and contact tracing here in the UK, something which has been shown to have an extraordinary benefit in Kerala, South Korea, Taiwan, Iceland and Germany (as just five examples – there are plenty of others from Africa and Oceana also), it felt like there was a collective sigh of relief across the country. Finally, someone actually publicly stated that things have gone wrong. Since that time Prof Tim Spector has warned us that because the UK has been listing only a limited number of possible Covid-19 symptoms, there are probably between 50000 and 70000 people who currently have the disease and are not self-isolating. He, along with Deputy Chief Medical Officer, Professor Jonathan Van Tam have both also insinuated that the ‘tried and tested’ method of physical contact tracing through local public health teams is much more trustworthy than a centralised app-based model. Without this, the ‘R’ number is very limited in it’s ability to predict much at all, as we’re really in the terriotry of good guess work, rather than more real time data which we can interrogate and probe more thoroughly. The danger with this approach therefore is that we are 3-4 weeks behind with the actual numbers and looking at death rates doesn’t necessarily help us much either when considering the rate of spread. To make matters more complex, the (inaccurate) R number has significant regional variation, which again makes the case for more locally led and connected decision making. Furthermore, the UK Pariliament’s Science and Technology Committee, chaired by the Rt Hon Greg Clark MP have detailed ten significant findings and concerns with recommendations attached, whilst recognising the complexities involved. Of particular note, we’ve had 10 weeks in which woefully insufficient testing, contact tracing and isolation has been the reality. Today, the WHO reported the largest number of new cases of Covid-19, worldwide. With our airports still open and an increase in travel emerging, we put ourselves at major risk of an early second wave, especially if we do not have the necessary systems in place to prevent this. Boris Johnson is still adamant that things are steaming ahead nicely but other government ministers say their new track and trace system will not be ready for roll out on June 1st. This is different to having a fully operational system in place. There are questions that still demand answers! Many expert voices are calling for a much more locally driven, joined up approach, led by our brilliant Directors of Public Health, supported by joined up working across the public sector and supported by General Practice. There are plenty of voices asking us to pause and think again.

Thirdly, we need to know if it safe for children to go back to school? The government are confident and clear that it is. It is interesting, however, that allegedly every member of the current cabinet sends their children to private schools, none of which will be opening until September. The answer to this question is not straightforward and there are several things to consider and we should be honest about that. Are children likely to become unwell from Covid-19, if they have no underlying health conditions? No – they are very likely to only suffer very mild symptoms, though there are some concerns regarding some children having rare sudden respiratory symptoms. But what about the impact on those who will need to continue to be isolated at home? Can children have the virus without showing symptoms? Yes. Can they therefore be spreaders of C-19? Yes they can, and because we have not been doing effective testing, contact tracing and isolation, this could be problematic. If the government’s testing and contract tracing system, run by Deloitte’s and supported by the national app is up and running by early June, will this make it safer? Probably, but there is great cynicism in the world of Public Health that this approach is desirable. As stated above, the tried and tested model of this all being run by the Directors of Public Health and their teams in each geography, supported by local GPs is deemed to be much more effective. Local knowledge and guidance would, I believe, give local teachers much more confidence with more readily available advice where needed. Should staff be wearing face masks? There is varying advice on this. Our local authority currently says no, but Prof Trish Greenhalgh from Oxford University advises that they should, on the basis that face masks reduce the spread of C19 and can perhaps offer some protection for the wearer also.

What are the risks of not opening the schools? Well, we know that 10% of all children in the UK (and this is not dependent on social class, so kids at private schools are at just as much risk) are likely to be suffering from 4 Adverse Childhood Experiences. The impact of this kind of trauma on them can be absolutely huge in the long term and schools and key relationships with teachers/TAs can be significantly protective factors. Schools also play a very important role in tackling food poverty and ensuring many children get 2 or even 3 good meals. So Steve Chalke is right that not opening schools could appear like a middle-class luxury. But will putting kids who need security and love, into an alien situation with facemarks, social distancing and a very different kind of day to usual, actually compound the sense of trauma? We don’t know yet, but we will need to watch this carefully, if and when the schools do go back. Perhaps headteachers could prioritise those children most at risk, over the 4 and 5 year olds, who it will be very hard to keep socially distanced. What I will say though, is that headteachers are not the ‘bad guys’ here. I don’t know one headteacher who doesn’t want anything except the best for the children in their school and genuinely wants to be able to have them back.

Without effective or sufficient testing and contact tracing, we do put ourselves at risk of an early second peak. This is a risk – are we prepared to take it in the face of what we know about the rise in domestic violence, childhood trauma and growing mental health issues? Will 6 weeks back at school before the summer really be worth it? Should we mitigate the risk by not opening and ensure that we are more sure of the necessary processes being in place first? The decision ultimately belongs with each head teacher with support from their governing body, as to whether or not to open on June 1st. It is dependent on what is practicable in their given location and with the staff and facilities they have at their disposal. The government guidance is difficult to implement in many settings. So let us be kind to each other. Let’s be honest about where we are and just how complex this is. For those who want to dip their toe in and give it a go, we must ensure that guidance is followed as closely as possible, especially hand washing, cleaning of surfaces and physical distancing, where practical. For those who decide to wait, fair enough. But whatever happens, let us be determined to build an education system that is fit for the future. Let us rebuild education based on love and kindness and let’s be brave enough to redesign the curriculum around the needs of humanity and the ecology.

So, in summary:

These are my own opinions
Is it safe for children and teachers to go back to school? Possibly, but without satisfactory testing, contact tracing and isolation in place and with growing evidence that this will not be adequate by June 1st and with an inaccurate R number due to an incomplete list of symptoms for testing people, there is a risk to the wider public that we could enter an early second peak. It would be prudent for the government to seriously reconsider their centralised approach to this, when empowering local government and public health teams to lead this process will be far more effective. It may be safe for children to begin to return to school (I think), but maybe not for wider society.
At what point then, would it be safe for schools to reopen? Perhaps once we are more sure that the protective public health systems we need to be fully operational are in place and running effectively. But we do need to return to school soon, so we need to find a way through – that way is unlikely to come through centralised command and control but will rather require a participatory and inclusive approach. So the answer is maybe but maybe not quite yet – better to get it right than to risk getting it horribly wrong by rushing it.
If schools choose to reopen, due to the concerns about issues like trauma, mental health and hunger, what are the issues they need to consider? The current government advice on social distancing is impractical and schools may need to look for community partners, who may be willing to help with other local premises (e.g. churches, mosques and local halls) to enable this to be possible. They will also need to ensure good hand washing, cleaning of surfaces and consider what they want to do about face masks AND we need to re-emphasise this advice to the wider public. Schools will also need to think about how they staff the recommended ‘bubbles’ and whether or not they will need community DBS-checked volunteers to help out. On top of this they will need to consider who they initially prioritise how they support the emotional and mental health of our children, young people and staff in a very different kind of setting. And they will need to remain inclusive of those children and young-people who cannot return to school due to having underlying health conditions themselves or in their households.
Whatever happens, let’s ensure a more participatory and inclusive conversation about the path ahead of us. Schools need to be involved in the process.
Let us also have a wider conversation about the kind of education system we need for the future. Lots of good thinking on this already across the UK and some podcasts coming soon.

Reimagining Health and Care – An Apocalyptic Moment?

There is a ‘kairos moment’ available to us to reimagine how we think about health and care, here in the UK and indeed globally. It’s true that COVID-19 is going to continue to take our attention and shape our health and care services in a particular way for many months ahead. But some have been talking about COVID-19 as an apocalyptic event. The word apocalypse literally means “to lift the veil” i.e. it causes us to see what is behind the facades. Therefore, if we are living through some kind of apocalypse, let us see with new and clear eyes what it is showing to us. If the facades are down – what is it that we are now seeing in plain sight, which may have been previously hidden from us and what are we going to change as a result? COVID-19 is exposing for us, yet again, what Michael Marmot has been telling us for years, that poor health affects our economically poorer communities and poverty kills. We cannot ignore the greater impact felt by those of our BAME citizens and what this speaks to us. We see the burnout of NHS and Social Care Staff highlighted by Prof Michael West, even more clearly, just how valued they are by the public and the unsustainable nature of their workload, caused by long hours, high demands and under resource. So what kind of health and care service does the future need?

In the UK, we have a health system that responds brilliantly to crisis (in the most part). We’re by no means perfect, but we do acute care really rather well. But overall, although the WHO rates our health system as one of the best in the world, our current system approach is not tackling health inequality, it is not coping with the huge mental health crisis and it is floundering with the cuts to local government and our ability to work in an upstream preventative way. Meanwhile, our over-busy, over-hurried workforce don’t have the time to really care for themselves (thus huge levels of burnout and low staff morale) or bring genuine, lasting therapeutic healing to our communities. I cannot tell you how many NHS and Social care professionals I see in my clinic at the point of despair. I know of whole social care teams who have cried under their desks and vomited into the bins in their offices because of the untold pressure they feel under to manage hugely complex and unsafe portfolios. Now is the moment when we have to grasp the nettle and accept that we can’t go back there. I don’t want to. My friends and colleagues don’t want to and truly, we simply can’t afford to.

Our health and care system tends to focus on short-term (political) gains and quick, demonstrable change, rather than the bigger ticket items around genuine population health. Sometimes we just change things for the sake of changing things but without a focus on what it is that we really want to see change. It’s exhausting. We can quickly build several new Nightingale Hospitals (which thankfully we haven’t needed), but we haven’t been able to ensure wide-scale testing, contact tracing and appropriate isolation. We can easily promise to build 40 new hospitals and feel excited by this prospect, but we have seen a decreasing life expectancy in women from our economically most deprived communities and a worsening gap in life expectancy. We need a health and care system which creates health and wellbeing in our communities, while maintaining the ability to respond to crises.

My friend, Hilary Cottam has written in her book ‘Radical Help’ abut the reimagining of the Welfare State for the 21st Century, with some superb examples of what can be made possible, especially within the realm of Social Care, for all age groups. Where this was applied most widely in Wigan, under the beautifully humble, kind, collaborative and inclusive leadership of then Chief Executive, Prof Donna Hall, the results were and continue to be staggering. One of the devastating parts of Hilary’s book is to read her chapter on experiments in the NHS. They were hugely successful, saved money and delivered better care, but when push came to shove, commissioners couldn’t extract funding from where it was to invest in the ‘brave new world’. It would be possible to conclude that the kind of transformation we need to see in the NHS is not currently possible – partly related to culture and partly because of centrally driven targets, which make brave financial choices hard to make with associated adverse political backlash. But I remain optimistic! As we look towards a desperately needed, more integrated health and care system, I believe if we applied Hilary’s 6 core principles with some audacity, we might see some amazing things occur in our communities.

For me, the change must begin from the inside – if we do not get our culture right (and we still have some significant issues around bullying, discrimination, staff well-being and poor citizen care) then it won’t matter what we do structurally or how we reorganise ourselves. If you haven’t seen my TEDx talk about how we create the kind of culture that allows us to do this, then you might find it helpful to watch it here.

Hilary’s six steps give us a really good platform from which to reimagine and build a health and care system fit for the future that is calling us:

Grow the Good Life!

We know that COVID has primarily affected our more economically poor areas with a significantly higher mortality rate. This is not news, but perhaps we see it more starkly in the light of this current pandemic. Michael Marmot has been telling us this for decades but his recent report (link above) highlights for us the decline in health outcomes and worsening health inequalities, since 2010. Firstly, we must recognise that the good life is not supposed to be only for the rich and nor does money necessarily lead to a ‘good life’. The good life is for everyone, everywhere. Secondly, we must accept that the good life is something which is not shaped by the powerful on behalf of communities. It is grown, fostered and tended by communities themselves, who own the mandate that ‘nothing about us without us, is for us’. Thirdly, we must therefore stop taking a reactionary approach to health and care and create wellness in and with our communities, determined to break down age-old health inequalities, tackle poverty, poor housing and climate change. We must accept that we cannot fix the problem and there will be no real health for our communities unless we cultivate the space for the good life to grow. A good place to start would be with a Universal Basic Income. It also means working across the public and business sectors to think about how we can be good employers and create the kind of jobs that the world really needs in the 21st Century – I’m excited to see that conversation alive and well, here in Morecambe Bay, particularly in Barrow-in-Furness and in Lancaster and Morecambe. It means ensuring that everyone has a home and access to good and clean transport. The good life must include a good start in life (and reverse the tide of childhood trauma), good opportunities to learn and develop (within a reset learning/education sector), good community, good work, good ageing and a good death. The good life enables us to be a good citizen, locally and globally and therefore the good life leads to a regenerated ecology. The good life must also include a good safety net if life falls apart or hard times come and really good care for those who live with the reality of chronic ill (physical and/or mental) health. The good life ensures that the elderly are honoured and cared for. It cannot be stated strongly enough that if we do not grow the good life then we will continue with the same old issues and the ongoing inequalities for generations to come. Health is primarily an economic issue and so all economic policies and choices show us who and what we value. Where do we need to shift our priorities and our resources in order to grow the good life together? Let us see beneath and behind the facades exposed in this moment and be determined that together we must co-create a much kinder and more compassionate society. There are so many economists (e.g. Mariana Mazzucato on how we create value, Kate Raworth on an Economics worthy of the 21st Century, Katherine Trebeck on why we need a Wellbeing Economy) doing great work on this. Why aren’t we listening to them more? Perhaps we are. 80% of people in the UK now want health and wellbeing to be prioritised over Economic Growth!

Develop Capability

Cormac Russell, the fantastic advocate of ABCD and all round champion of community power recently said this:

“The truth is, ‘the needed’ need ‘the needy’ more than ‘the needy’ need ‘the needed’. Society perpetuates the opposite story; because there’s an entire segment of the economy tied up in commodifying human needs. It’s a soft form of colonisation. That’s what needs to change.”

Perhaps, if the NHS and/or Social Care were a personality type on the Enneagram, it would be Type 2, or in other words it has a need to be needed. Perhaps we are the ones afraid of removing the ‘medical model’ and trusting people and communities to figure it out themselves – time, as we often say is a great diagnostic tool and a great healer. Many little niggles and issues often sort themselves out on their own, or with a good listening ear, or a change in diet, or some other remedy. What if, instead of trying to manage unmanageable need (at least a portion of which we have created ourselves by the very way we have designed our systems and through the narratives we tell our communities), we develop real capability in and with our communities? We have been interested in the world of General Practice how many people haven’t been in contact with us during COVID-19. I think the reasons for this in some ways are obvious (people were told to stay at home and so they did just that, and they wanted to protect the NHS, so they didn’t want to bother us) but in others are perhaps more complex and not necessarily altogether good – meaning we are seeing far few people with potential symptoms of more worrying conditions, like suspected cancers of various sorts. How do we design a system that starts with the good life, enhances community well-being, enables better collaborative care within and from communities themselves, whilst being able to respond to real need?

Surely people who live with various health conditions, or who have social needs should be in the driving seat when it comes to understanding their own condition or situation, recognising what their options are and deciding how to manage the care they receive. We must take a less paternalist approach to health and care and focus much more on coaching, empowerment and collaboration. Services will only really work for the people who need them, when they are co-designed by them. We will find this is much more cost effective, wholly more satisfying for all involved and will create a virtuous circle in creating the good life. Social prescribing goes some of the way, but is still way too prescriptive. This is about taking a step back and building understanding and creating more capability to live well in our communities, by focusing on a building on the strengths which are already there. We will only do this if we dare enough to really listen, putting aside what we presume we know and start a new conversation with our communities about what we really need together. We can do this in multiple ways, making the best use of available technology.

Above All Relationships

I believe relationship is pretty much at the heart of everything meaningful. If we’re really going to create the kind of health and care system that is fit for the 21st century, it’s not that we need to be less professional, it’s that we need to become more relational, step out from behind our lanyards and turn up as human beings first and foremost. When we really listen to the communities we serve we discover what a wasteful disservice we provide to the public in our current transactional approach. Yes we tick the boxes that keep our paymasters happy and fulfil our stringent KPIs, but in doing so, we spectacularly miss the point. Hilary’s chapter on the power of relationships in family social care is particularly poignant on this issue. If we plot the kind of interventions we make with perhaps the most troubled members of our community from a social care, mental health, policing and physical health perspective; we find that we make hundreds of contacts, spend an inordinate amount of money and see very little change for the fruit of our labour. What a waste! But when we ask these families what they really need, what their hopes and dreams are and how we might work with them to make this possible – yes there are bumps along the way, but we find with smaller and less expensive teams, we can achieve far more, because relationships are consistent, build trust and create the environment needed for real support and transformation. Why would we persist with a model that is outdated and doesn’t work?! Why are we afraid to work differently? We have to stop doing to and be together with. I believe Primary Care Networks create the kind of framework that begin to make this more possible. I think that if we see health visitors, school nurses, physios, SLTs, OTs, mental health teams and social workers integrated into these teams, we will see far more joined-up, cost-effective and relational care in and with our communities. In some ways, it doesn’t even matter who the ’employer’ is as long as we allow teams to work in a really inter-dependent way.

Connect Multiple Forms of Resource

If we keep working in silos and continue to measure outcomes by single organisations, we will continue to fail the public, waste money and exhaust our staff. However, if we can agree on good outcomes in collaboration with the public we serve, join up our local budgets, share our public resources and empower our teams to work in a truly integrated and collaborative culture (as has been happening through this pandemic), then we can begin to make a real difference where it is needed and see lasting change in our communities. In Morecambe Bay, our integrated teams are working in this way but there is more for us to do and further for us to go. One of the things I have particularly loved about the Wigan vision is the core 3 things they ask for from all their staff – Be Positive (take pride in all that you do), Be Accountable (be responsible for making things better), Be Courageous (be open to doing things differently). Three simple principles have enabled a fresh mindset and a new way of working which is clearly seen across their public sector teams and in the community at large. If we don’t learn to co-commission in partnership with our communities and across our organisations, we will not shift the resources from where they are to where they need to be. It’s definitely easier in the context of a unitary authority, but not impossible, if the relationships are good, in other contexts also. However, as Donna Hall argues, commissioning often gets in the way and is a blocker, rather than an enabler of resources getting into the right places because of the rule books involved. Her experience and track-record are well worth listening to, uncomfortable though they may be for those of us who work in commissioning organisations. Scotland doesn’t commission health and care in the way England does – are there lessons to learn? I don’t know the answer, but it is worth a conversation. What we do need for sure is thinner walls, blurred boundaries, greater humility, genuine trust, greater collaboration, real honesty, mutual accountability and true integration between ‘sovereign’ public organisations and the overstretched and over-burdened community-voluntary sector and yes, the private sector (….this talk by economist Mariana Mazzucato on how innovation happens is really worth thinking about). If we allow ourselves to do this, we will be on the way to a welfare system that is much more sustainable and practical.

Create Possibility

Go on! Try it! It’s OK to fail! We’ve got your back! If it seems like a good idea, give it a try! These are things we need to say and hear much more in the world of health and care. Of course we need to be guided by evidence, but there are so many things we do every day, because ‘that’s the way we do it’, often governed by a culture of fear. What might be made possible if we garnered a real sense of innovation, creativity, bravery and experimentation instead? But this must not just be limited to our teams. What are the possibilities within our communities. How do they see things. What hopes do they carry? What opportunities have they noticed for more kindness, better integration, smarter working and improved services? Are the services we provide really meeting the need? If not, what is possible instead? There is an ancient proverb that says: “Hope deferred makes the heart sick, but hope coming is a tree of life…” I wonder how much of the current ‘sickness’ we see in our communities is because people have lost a sense of hope that they can be part of any meaningful change. Just imagine how much life, health and well-being would be released into local streets and neighbourhoods, simply by including people in the participatory experience of dreaming about and actually building a better future that is more socially just and environmentally sustainable. In Wigan – this looked like The Wigan Deal. We need to take a similar approach everywhere – it’s not about replicating it – it’s great to learn from best practice and implement it more widely. But it’s also important that we start from a place of deep listening and creating hope and possibility. Change happens best when it comes from local, grass roots communities, who love and take a greater sense of responsibilities for the areas which they know and love. If this is going to happen, we have to embrace the notion of New Power!

Open: Take Care of Everyone

Our target driven culture is the enemy of creating really good health and care in our communities. Small minded, measurement-obsessed, top-down, KPI-driven, bureaucratic micro-management is strangling the life out of our public services and preventing us from reimagining a welfare state, especially concerning social care that we so desperately need. We can no longer tolerate the staggering inequalities experienced by our poorest communities and therefore we can no longer contemplate continuing to accept the silo’d and misaligned (under) funding of local government, social care and the NHS. If we are going to have a society that is caring to everyone, no matter of their age, gender, genome or race, then we must be determined to build a system on the values we hold dear of love, hope, inclusivity, joy and kindness. There is no way that we can do this from within the system alone. But the future is calling us to explore new paths together and build a system with much more flexibility and adaptability. This is not outside of our gift, nor beyond our reach. We cannot do it alone. But if we let go of any fear of localism and wide participation, then together, with our communities, in the places where we live, we can create a society that truly cares.

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