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.
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).
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.
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 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?!
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!
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:
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.
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.
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 theburnout of NHS and Social Care Staff highlighted by Prof Michael West, even more clearly, just how valued they are by the publicand 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!
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.
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.
So many voices are saying that we can’t go back to how it was. We don’t want to live at the same old exhausting pace anymore. We don’t want to continue to harm our environment nor accept such staggering inequality. This quote below is actually from Sonya Renee Taylor, not Brene Brown!
One of my favourite stories to read my kids when they were younger was ‘The Great Green Forest’ by Paul Geraghty . It talks about the destruction of the Amazon Rainforest and how one day, the man on the digger stops and listens to the forest and realises he can’t do his job any more. He can’t be part of this destructive way. So he gets off and walks home and never returns, whilst the forest envelops his old machine and regenerates. It used to choke me up and the kids would look at me and wonder why I had tears strolling down my cheeks! Our world does not have to be shaped by the idea that we are ‘homos economicus’ – the selfish, self-centred, self-made man of the neo-liberal era. That is OVER! And all neuroscience and developmental psychology points to a very different reality anyway – one that we have perhaps been blind to. The truth is, we’re actually wired for empathy and compassion, but the systems we have created have warped our behaviour. But through all the pain and difficulties of COVID-19, something in our corporate memory has been awoken of our interconnectedness to the family of humanity, other species we co-exist with and the biosphere we co-inhabit together. We simply cannot go back to how things were – everything has changed.
Change doesn’t just happen because we want it to – that’s a good start, but vision alone is not enough! I’ve been spending a bit more time in my garden of late. I love gardening. For me it is the place of my best personal development and growth. Last year, I let the whole garden be fallow – I just left it. This year, when I came to plan what I wanted to grow, I found that I have a lot of clearing to do. There are things I need to “uproot and tear down, destroy and overthrow”, before I can “build and plant”. It’s particularly amazing to me how florid certain weeds, like creeping buttercup, can be! The networks of roots in the soil, take quite a bit of digging out. For me it’s a great metaphor for our mindsets, fixed beliefs, thought patterns and subsequent behaviours. If we’re going to make space for a kinder and more empathic, life-giving way of thinking and being in the world together, then we have to be willing to root out our old ways to make room for that which we want to plant and sow.
To take this garden metaphor further, once the ground is clear, my seeds aren’t going to grow on their own and I’m not going to cultivate a harvest overnight. I am going to have to work the land (thankfully some of this has been done by previous garndeners and I am grateful for what they have sown). I am going to need to build frames to enable good growth and ensure the soil remains cared for and the plants watered. I’m going to have to protect the seedlings from birds, rabbits, slugs, flies and all kinds of other pests, whilst recognising there is providence for them too! There is a tenderness and a ferocity to gardening that helps us to think about how we co-create and labour for the kind of world we want to be good ancestors of.
And so let us do the work together. Let us clear the ground, begin building the frameworks we need to co-create the world our hearts are longing for. In Morecambe Bay, we’ve been thinking about the areas of politics, economics, society and ecology. There are many others, but here are some things we might want to consider and build towards (there is further reading/material to engage with if you feel like going a bit deeper In the hyperlinks):
Here in Morecambe Bay, we’ve been exploring what it might mean to develop a politics of love and kindness. We agree that the basis of a politics of love is friendship, deep listening and the embrace of the ‘other’. It means loving our enemies, doing good to those who may seem to want to harm us and choosing the way of peace. It involves seven key principles:
prioritising the poor
protecting and promoting the wellbeing of children
instating women to ensure full equality in everything
caring for the sick
restorative justice for those in prison
welcoming strangers – particularly refugees and asylum seekers
caring for the environment in which we live (locally and globally) by being responsible in how we steward the earth’s resources
What does that mean in practice? It means holding spaces for communities to come together and talk about the issues that really affect them. We’ve found the Art of Hosting really helpful in creating a framework to do this. It means deliberately building relationships with ‘the other’ through initiatives like ‘The Poverty Truth Commission’. It means creating trauma-informed practice and building a culture of hope. Do we dare to do the work required to reimagine, reinvent and reinvigorate this space? Can we throw off our apathy and cynicism and engage with the stuff that shapes how we do life together? We must embrace a politics that is much more local, participatory and engaging.
Shift from an economy focused on aggregate GDP growth to differentiate among sectors that can grow and need investment (critical public sectors), and sectors that need to radically degrow (oil, gas, mining, advertising, etc.)
Build an economic framework focused on redistribution, which: establishes a universal basic income, a universal social policy system, a strong progressive taxation of income, profits and wealth, reduced working hours and job sharing, and recognises care work.
Transform farming towards regenerative agriculture based on biodiversity conservation, sustainable and mostly local and vegetarian food production, as well as fair agricultural employment conditions and wages.
Reduce consumption and travel, with a drastic shift from luxury and wasteful consumption and travel to basic, necessary, sustainable and satisfying consumption and travel.
Debt cancellation, especially for worker and small business owners and for countries in the global south (both from richer countries and international financial institutions).
Hickel is clear. “We have a word for what’s happening right now: recession. Recessions happen when growth-dependent economies stop growing. It’s really important also that we don’t confuse economic de-growth with economic contraction. One is pressing the brakes to avoid a collision. The other is a compete and utter car wreck. When a tree or human or any natural organism reaches full adult size and stops growing we call it “maturity”. We would never call it “stagnation”. That we routinely use the latter term to describe the economy shows that we have no plan, no end in mind… just perpetual expansion. What we need is to build a different kind of economy altogether: an economy organized around human well-being rather than around perpetual growth.” Kate Raworth’s work on the Doughnut Economy is another way we can think about the future. It’s so exciting to see the City of Amsterdam adopting this as their model for the future.
We need a welfare system that is primarily shaped by relationship. Hilary Cottam’s six foundational insights on how to do this are so much food for thought.
In this one page Hilary exposes everything that is wrong with our current system and gives us the permission and the flexibility we need to reimagine and implement an altogether kinder and more practical solution to the issues we face in the 21st century.
Two of the core pillars of the welfare state (and btw the concept of state needs to be fully reimagined also, if we are to create a just and fair world in which we live in peace together) are education and health. Both need reimagining and there isn’t space in this blog to go into all of this now, but here are some thoughts on where education and health need to move towards, but Hilary’s principles can be applied to these and many other sectors also.
There are so many incredible voices speaking into this right now and the earth is literally groaning for us to listen to what it is saying to us. Can we listen to the narrative of The Great Green Forest? Will we allow ourselves to be forever changed, to repent of our abusive and unkind domination of the ecology, and turn instead to the gentle stewardship of the land and all living creatures to which we are called? There are so many prophetic figures calling us back to this original purpose of humanity. One of my favourites is Alastair McIntosh. This is well worth a listen, if you’ve not heard him already.
The tectonic plates are shifting. We are moving from a patriarchal, toxic-type of masculine and dominant-sovereign understanding of how we shape the world towards a much more feminine, inclusive, collaborative and empathic one. Embrace it. Nurture it in yourself. Let this fresh wind blow fully in your face and shake off the dust of the past season that clings to you or the cobwebs which pull you back. The future is calling us. Can you hear it? Listen. Take a breath. Open your eyes. See what lies ahead. Link arms in hope and determination. Let’s go there together.
The world has changed. We cannot go back to where we were, nor continue to head in the same direction we were set upon before this crisis. But that is easier said than done and will be impossible if we do not embrace the grief of what we are journeying through together. There has been and continues to be painful loss. We have lost dear friends, family members, neighbours and colleagues. We have lost jobs, income, holidays and social gatherings. We have missed births and birthdays, key social events, final goodbyes and funerals. We are bereaved of whole ways of behaving – our ways of life, everything we’ve known has been entirely interrupted.
For me, as a type 7 on the Enneagram, it’s all too easy to engage in the future, to think about the ‘what next?’, to avoid the pain of the here and now, by letting my imagination run wild of what the world might be like instead. But we cannot and must not miss the vital part of our current journey, which is to recognise, embrace and partake in the grieving process. Grief is not comfortable, it is not easy, it is not enjoyable – in fact it is both tumultuous and painful…..but it is good. Refusing to enter into it, or trying to suppress it, will only lead to a deepening of the trauma and a delay of this inevitable experience.
The thing about grief is that it is unpredictable and what makes it even more so in this current experience is that it is both personal and corporate. However, the cycle of grief is well known and although each of us will go through the cycle differently, it’s worth recognising where in the cycle we might be, both as individuals and as a wider community/society.
This is the classic ‘grief cycle’ (I’ve borrowed the graphic from psychcentral.com) and it demonstrates well how the experience of grief is neither straightforward nor easy. However, psychologists agree that each of us will pass through each of these phases, no matter how briefly – though we can remain stuck in some areas for quite some time.
The isolation of this time has been the starting place for most of us. For some that was coupled with an acceptance that we are where we are, but for others there was a denial that this could be real and a refusal to engage with the idea of social distancing (although with police enforcement, this quickly began to change!).
The anger phase is clearly present for many at the moment, and understandably so. Anger is not wrong, it’s how we respond to it that becomes the issue. Sadly, in many households we’re seeing a rise in Domestic Violence , particularly towards women and children and this is something we need to take really seriously. Learning to control our anger and find a positive outlet for it is absolutely key. There are all kinds of online resources to help with this, but the deep cuts to social services and policing over recent years have made it difficult to work with families in a more proactive way. The Violence Reduction Unit in Lancashire, led by Detective Chief Superintendent Sue Clarke, who is a brilliant leader, have done some incredible work in this area over the past couple of years, which is well worth learning from. The approach is much more productive than traditional methods of dealing with this issue and involves being with families more proactively to bring restoration and redemption into broken situations.
These are all important questions that require an answer. Anger can be used to facilitate the right kind of conversations to bring challenge to the status quo and demand that it never leads us here again. The outcomes we are seeing were not inevitable – so what will we learn? What will be different? How will we change? If people in positions of power are willing to own up to mistakes, are we willing to forgive? I hope so…..how do we rebuild society otherwise? We must be able to learn and change our ways. It’s at the heart of what it means to love. But we must also recognise that some of this anger is simply part of the grief cycle and there may be no answers. We’re angry in part, because we are grieving. Sometimes our anger brings challenge and change, but sometimes we yell into the night and are met with silence.
Depression in grief can become clinical depression, but the word, in the context of grief, more describes a sense of deep sadness, loss, numbness, apathy and is often accompanied by tears. We must not try and keep a stiff upper lip, or push this away. Some of us will feel this more acutely than others, depending on our personality type, but this is a vitally important part of the process. This deep sadness can catch us unawares. It can come almost out of nowhere and we can find ourselves having a good cry in the bath or struggling to find the motivation to get out of bed of a morning. Talking about these feelings is absolutely vital, and it’s important that those of us who listen, ensure that the person experiencing these emotions feels heard. They don’t need fixing. They need validating. They need to know it’s OK to feel like this. We can’t just wish it away or get back on with things. There is a certain wallowing in this place that is extremely healthy and right. It’s true, we don’t want to get stuck here, and by putting some positive measures in place, like exercising, eating well, mindfulness and keeping a positive sense of routine, we can avoid becoming more mentally unwell. However, we must not try and rush through this phase or refuse to embrace the pain of it. But this can become a very dark experience and some people will wonder if life is even worth living. We can find ourselves asking searching questions: Can we really go on without our loved one? Will we ever get through the brokenness of this current situation, when we have lost so much? If this becomes overwhelming or there are serious thoughts of not wanting to carry on with life, this is where therapeutic interventions or medical treatment in the form of medication can be really important and literally life-saving.
At a corporate level, we share a sadness that 20000 people in the UK and 200000 people globally have lost their lives so far, due to COVID-19 – and that is just the recorded deaths. We will potentially feel lost that a whole way of being together is no longer possible, nor perhaps, desired. The artists will help us the most here. Songwriters, painters, choreographers and playwrights. Are we mature enough to embrace the songs and dances of lament? DO we know how to do this?
Bargaining is about us trying to begin to formulate some meaning or sense of what has happened/is happening. We might find that we want to talk about our experiences more, tell our stories, reach out to others and explore some of the ‘why’ questions we’re wrestling with. We might find we start ‘big conversations’ with God or ‘the universe’ – some thing like – ‘if you help me get my job back, then I’ll live a good life from now on’ or we might find we’re dealing with several regrets in our interactions or relationship with the person we have lost.
Acceptance is about realising that we are where we are and we cannot change a thing. It allows us to breathe deeply into the reality of the horrors we have walked through and begin to face into the future. Some people think of the grief cycle as more like a river with the grief cycle being a whirlpool that we get stuck in for a while. We go round and round, but eventually we come out the other side. On a personal level, perhaps, before we entered the whirlpool, we had a dearly loved one in our boat with us and we entered this whirlpool once that person became sick or was no longer in the boat with us, because they had died. The whirlpool can feel overwhelmingly difficult, with the stages above. We come out of the whirlpool with an acceptance that this dearly loved person is no longer in the boat with us….but there are other boats that we travel alongside, and perhaps there are others who still remain in our boat. We must now learn to live in this boat, without the person who was with us before but knowing we can face the future with our other companions. At a corporate level, this is about us sense making that the future cannot be like the past. Things have fundamentally changed. We cannot go back to how things were and so together we can build an altogether fairer and kinder future for our global population and the planet we inhabit together. This becomes what some refer to as the 6th stage of grief – ‘Meaning’. We begin to make sense of what we have journeyed through and use it to transform our experience of the world and how we want to live in it. My next blog will explore some of the meaning we may find the other side of COVID-19.
Whatever your experience of grief at this time, embrace it and talk about it, but don’t try and hurry it away. Good grief is a part of life and enables to process our loss, feel our pain, heal our wounds, accept our scars and find a new future. The ‘Good Grief’ movement is something I would really recommend exploring, especially if you are struggling to process your own grief. There is also lots of mental health support available through your local GP or online via nhs.uk. Grieving allows us not only to engage with the pain we are going through, but allows us to let go, so that we can reset and rediscover a way forward together. It’s impossible to walk through it alone, which is why as the city of Liverpool reminds us in the amazing song, sung at Anfield, friendship is everything.
Kate Raworth’s work on the Doughnut Economy over the last few years has been nothing short of extraordinary. She has torn up the economic text books of the last 150 years and asked some much better and kinder questions about the future we need. It is so exciting to read that in collaboration with Janine Benyus, using biomimicry, the model is now being implemented in the City of Amsterdam. It opens up a world of possibility for a reimagined future, in which our world becomes regenerated for both people and the planet itself.
Kate’s book and then her blog deserve serious attention and, in my opinion, a Nobel Prize! There is no way in this short blog that I can even begin to explore the exponential potential of the work, but I do want to highlight some of the key issues. So many people are saying that we simply can’t go back to how things were prior to Covid-19. If we’re serious about that statement then we need to begin thinking about how we will experiment with alternative models and ways of being together that will be good for the future of the environment and create a much more socially just framework for the global family of humanity. I love this model that Kate offers in thinking about what is important for a place – it contains four key aspects. Local/Global – Social/Ecological.
We can apply this model to any city or given area, and it allows the people of that place to work with the uniqueness of their geography and demography. I believe it is a really helpful and holistic model when thinking about population and planetary health.
There are then several aspects if a group wish to move from understanding their region to bringing about transformative action. Kate calls these the 8 M’s.
The model then includes 4 really helpful sets deeper questions to create the framework around the local/global – social/ecological foundations.
Firstly – what does it mean for people to thrive within their own Geography?
Secondly, what does it mean for the local environment/ecology to thrive and regenerate?
Thirdly, how do the local people contribute to the wellbeing of the wider family of humanity? How can they ensure they are good global citizens?
Fourthly, how does the locality contribute to the wellbeing of the whole planet, by how it behaves?
This way of working takes serious collaboration, co-production and real change-making. I love the way that Kate illustrates this:
Here in Morecambe Bay, we would employ things like ‘The Poverty Truth Commission’ and ‘The Art of Hosting’ to ensure that every voice is heard and we embrace ‘otherness’. It will involve partnership with the team at ImaginationLancaster, The Social Inequalities Research Centre and the Health Innovation Campus at Lancaster University, Cumbria University, The Eden Project and anchor institutions like our District Councils, County Councils, the NHS, BAE, EDF, School Federations, the CVFS and the network of SMEs. It will also mean developing the kind of culture I talk about here.
Out of the ashes of this devastating time, a phoenix can rise of a regenerated society and ecology. Are we up for it? I sincerely hope so and I wonder in how many places this can become possible. We need to create online and then, once lockdown is over, more real, radical spaces of hospitality and collaboration as we work together for the future that is calling us.
I tested positive for Covid-19 on Good Friday. As a doctor it’s always tough to be off sick – you feel a mixture of guilt (because you know how hard your colleagues are working), frustration (because you want to be back out there serving your community) and helplessness (because there’s nothing you can do about it). I knew I had the virus before my result came through – I felt like I’d been hit by a bus – like all the energy had been knocked out of me and I was very achey. This, along with the cough and other symptoms has made me stop. I am forced to rest. I can’t just continue. I need to let my body recover. Covid-19 hasn’t only shown us the fragility of human life, but of the way we have constructed our systems together – the vast injustices afforded to more than half the world’s population and the damage we are doing to the planet itself. This virus has created an enforced rest for the majority of us and made us stop. And whilst we do so, the earth itself is regenerating – perhaps we are too.
This weekend, along with millions of people across the globe, our family will be celebrating Easter. During this rest there is time for me to reflect again on that incredible story and think about its implications for the world. Easter, I believe, perhaps more than any other time, gives us space to pause and ask ourselves what life is really about – what is it that we’re really living for?
Easter can be thought of in many ways. It seems to me that we have entered a new space in recent years to be able to discuss issues of spirituality much more openly again. Here are a few ways that I see Easter, if you’re interested (!):
1) Easter is about new beginnings. The chance to start over, to see the world radically differently in the light of what God reveals to us about his own self-giving, others-empowering love. It’s an opportunity for us to press the reset button and find the grace and hope for the world to be made new. In the midst of the pain and complexities of the global lockdown of COVID-19, multiple voices are beginning to call for a reimagined world. Jeremy Lent writes powerfully about the reality that everything has changed. He states that the ‘neo-liberal era’ is potentially over and therefore we have an opportunity to reset the foundations upon which we build our lives together on planet earth, whilst working for its regeneration. It’s well worth making yourself a cup of tea and pausing to read his reflections.
2) Easter is about a new economy. Easter is about debts being forgiven and a resetting of our priorities. Never, in all of human history, has there been such stark inequality between rich and poor, nor has the climate ever faced such an emergency. Our economic systems are entirely defunct for the needs of the global population and the environment in which we live. The old lie that ‘there is no such thing as society’ is exposed for what it is and the story of ‘self-centred, selfish man’ as the basis on which to build economic theory is broken. In its place new experiments are emerging around economies of wellbeing. This week Amsterdam declared it is going to be the first ‘doughnut city’ in the world – read this and let your heart leap – we’re talking about the kind of economy that is regenerative and distributive by design! The world made new! Jesus proclaimed the economics of Jubilee – a forgiving of all debts and the chance for the people and the land to rest. So radical it was never adopted, but his manifesto has never changed. We have an opportunity together to embrace a much more loving and radical economics if we want to. We don’t have to continue as we were…..In fact there are fresh global calls to cancel the debt of developing nations – now that would be a reset!
3) Easter is about a new politics. Bishop Tom Wright calls resurrection ‘THE political act’. In other words, he’s saying that the ultimate power of the world is not that held together by the likes of Trump and Putin, but the life-laid-down-love of the cross – no power can overcome this love – it is the ultimate force in the universe and it is legitimated in the resurrection of the son of God, who lives this way and overcomes death itself and empire in all its forms. This politics of love is non-violent, enemy-loving and full of peace. It does not erect walls, it builds bridges. It is full of compassion and mercy. It always hopes, always trusts and always perseveres. Russell Brand and Brad Evans have a fascinating conversation about a new politics of love – something we have been actively exploring in Morecambe Bay (See Roger Mitchell’s brilliant talk). They discuss how this is anything but ‘airy-fairy’. Love, rather, as the ultimate foundation of how we build our lives together gives us an alternative reality on which to build a fairer and kinder society. Brand is not everybody’s cup of tea, but I like his ability to ask good questions and provoke our ability to think as we challenge our own presuppositions. Some people are now coining the term ‘glocalisation’ to think about how we become more locally focused, whilst remaining globally connected and concerned about the plight of others around the world. In other words, glocalisation enables a much more relational, loving, connected politics and economics whilst also enabling us to learn from other great ideas and initiatives around the world and care about our fellow human brothers and sisters more. The politics of Jesus is seen throughout his life and ministry and his death and resurrection makes it even more possible: prioritise the poor, put children in the centre, instate women, free prisoners, heal the sick, welcome strangers, renew the creation….not a bad starting point for a new world.
4) Easter is about healing. As we behold the wounds inflicted on God himself, we find one who is truly with us in our own suffering. His therapeutic healing is one which draws alongside to be with us in our pain and distress, washing our feet, bearing and carrying our infirmities with Him – sometimes that results in incredible miracles but often it’s just the knowing that he is with us in it that is enough. We see this kind of incredible healing at work through our health and care workers across the globe right now and in countless tales of lives poured out in service to others. The whole point of healing is to bring wholeness. I wonder what our health and care systems would really be like if we put wellbeing and wholeness at the heart of the design process.
5) Easter is about salvation and redemption. I personally cannot align myself with a theology of penal substitution. I don’t have time or space in this blog to say why, but would recommend ‘A More Christlike God’ by my friend Brad Jersak, or this blog to explore the issue further, if you’re interested. As we look upon the crucified Christ, we don’t look upon someone appeasing an angry Father, rather we see God himself, misunderstood and rejected, nailed to a cross, breathing out forgiveness and revealing to humanity that this way of life-poured-out-love is stronger than death itself. This way of life saves us from our own selfishness, greed and ego-promotion and invites us into something far greater and more beautiful. The invitation of Easter is to reset our relationships with each other, the earth and God himself; to discover that God IS love, not at all like an Imperial Sovereign, and the very nature of the Trinity is self-giving, others-empowering love! The truth is that unless we’re willing to deal with our own internal mess, our own ego-mechanisms and projections, then we will never heal the mess of the world together. The invitation from Christ through the ages is for each of us to take up our own cross, to crucify our own selfish nature, which fights against the way of love and put on the ‘new self’, to be made into new creatures and partake in the new creation.
I believe we have an opportunity in this time to rest, reflect, reimagine and reset. If we dare to ask ourselves some deeper questions and become uncomfortable with the answers we are discovering; if we can allow ourselves to feel some of the discord about the way things have been, but also recognise the fear we have of stepping into a different way of being together and the grief cycle we must enter to let it go; if we can embrace the inconvenient truth that the earth and the global poor are speaking to us about the unsustainable nature of our neo-liberal world, then perhaps we have enough critical yeast to change us and inspire us towards a new world together. I take great comfort in the idea that God is with us in this struggle and works through us, by his Spirit, to bring reconciliation to a broken society. Over the last few days I have heard my favourite childhood bible verse, from the prophet Isaiah, a number of times. I leave it with you as food for thought:
This time of Lockdown and Social Distancing, due to COVID-19 is not easy. It can have a significantly negative impact on our mental, physical, and emotional health and wellbeing. Difficult conversations are being had, isolation and loneliness are really tough and it’s particularly hard that we don’t know how long this period may last.
In this video, I share some ideas of the kind of things that can help us stay well. It’s by no means an exhaustive list, but hopefully helps us think about how we can stay well individually whilst also looking out for our neighbours. None of this is easy, but whilst we’re staying home to suppress the virus, stop the spread and give our health (and other front line) services the best chance of caring for people, we need to ensure we stay healthy and well, whilst building our strength and resilience. Together we can!