Tag: hope

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

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

 

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

 

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

 

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

 

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

 

The Wider Determinants of Health

 

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

 

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

 

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

 

Our Choices, Behaviours and Lifestyles

 

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

 

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

 

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

 

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

 

An Integrated Health and Care System

 

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

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

 

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

 

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

 

The Places and Communities we Live in and With

 

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

 

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

 

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

 

So Where from Here?

 

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

 

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

 

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

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To Hull and Back

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

 

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

 

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

 

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

 

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

 

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

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Cuts and More Cuts – a Disaster for our Population’s Health and Wellbeing

It amazes me, in this 24-hour news world that we live in, that a further £1 BILLION of cuts to our county councils doesn’t remain on the BBC front page until much past lunchtime! It feels a bit more important than some of the stories being picked by the editorial team instead!

 

https://www.bbc.co.uk/news/education-45573921

 

Anyhow….these cuts will be utterly devastating for our population’s health and wellbeing and the “extra funding” for the NHS is simply not going to be enough to undo the damage. Local government will have lost 60% of it’s budget by 2020, with devastating consequences and no amount of local taxation will replace the difference, especially in poorer areas of the country. And just look at what will be cut:

 

  • 58% of councils said highways and transport (including road improvements, streetlights, pothole filling)
  • 47% said libraries
  • 45% said early years and youth clubs.
  • 44% ear-marked public health services like smoking cessation, sexual health, substance misuse
  • 36% said children’s services.

 

 

So:

  1.  We will have far higher risk of road traffic accidents, especially for cyclists/motorcyclists (I’ve seen the effect of people hitting potholes and fracturing their spine).
  2. there will be less access to shops and leisure facilities for our poorest communities, meaning a worsening of the obesity epidemic.
  3. We will have increased social isolation and reduced learning opportunities for our elderly (therefore increasing risk of dementia and depression).
  4. We will have decreased social support for our young people, leaving them far more vulnerable to gangs and substance misuse.
  5. We will have less support for young families, struggling to cope and so less opportunity for parental support and an increase in Adverse Childhood Experiences – with devastating long term consequences for physical and mental health.
  6. Smoking continues to affect 1 in 5 people in a hospital bed, and is still the biggest cause of death in many parts of the country – yep good idea to cut that.
  7. Our drug crisis is rising exponentially, and we’re seeing an increase in STIs and yet councils will not be able to provide services to help.
  8. Children’s services, those vital safety nets that work to prevent serious safeguarding incidents will have to be reduced also!

 

WHAT?!

 

There isn’t a council in the country that wants to make these cuts and the lack of foresight by the government to drive these further cuts through when the ones we’ve had already have been so deep, is utterly ludicrous. I’ve sat with council officers in tears over the choices they are having to make – these are people who love the communities they serve and are trying to do as much damage limitation as possible, whilst being left to take the blame.

 

What does it tell us? It tells us a few things. Firstly, there is a serious lack of joined up thinking about the long term consequences of these cuts. Save money now, but pay for it 5-fold in the future. Secondly, there is a genuine lack of concern for the poorer communities in our country. Thirdly, our current political model is broken and more than ever we need a politics of love/compassion. Fourthly, our current economic model is caput and cannot give us the regenerative and distributive future we need for humanity and the planet. I feel so despairing, sad and am grieving what this is going to mean for so many of our communities. We need to feel this pain and face up to this and find hope in reimagining how we might do things radically but necessarily differently.  This piece in the Guardian is worthy of serious reflection:

 

https://amp.theguardian.com/politics/2018/sep/16/the-eu-needs-a-stability-and-wellbeing-pact-not-more-growth?__twitter_impression=true

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Health and Society – Can We Make A Difference? Part 2 – politics

In the second of this (actually 3-part!) series, I’m looking at how politics and social movement are vital at changing the health and wellbeing of our society, communities and the environment we live in. Together We Can!

 

 

 

 

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Creating a Culture of Kindness – Vlog

Here is Part Deux of my 3-part Vlog series on how we can create great culture in Health and Care Systems (or anywhere really!).

 

“Culture eats strategy for breakfast,” Peter Drucker, but I don’t think we believe this anywhere nearly enough!

 

 

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Authentic, Loving Leadership

Over the last year, I’ve had the privilege of spending some time on a leadership programme with the NHS Leadership Academy. One of the things it has helped me to do is talk more openly and honestly about what is important to me, what shapes me, what makes me – me! I have spent a great deal of time thinking about the word ‘authenticity’ and how I can be true to my deeply held values, no matter where I find myself, or whose company I may be in.

 

I did most of my ‘growing up’ at University with an incredible set of friends, who have remained at the core of my life. One of our founding principles as a bunch of mates was that we would not do fear or shame, but that we would be honest and open with each other about whatever we were going through. I found myself being able to talk about stuff that had been bottled up for years and making me feel rubbish about myself and as I did so, I found I was loved, not for what I did or performed but for who I was – just me, as me.

 

This kind of open and honest vulnerability sits as one of my core values in leadership because I believe it keeps me humble and permissions others to open up also. For some, there is a fear that if you show weakness, others may turn it against you – but that is a voice of fear that I personally will not succumb to. The depth of relationship that we form in any team is determined by our own ability to open up and show our true colours. I believe that being honest about where we are failing or weak allows others to be honest too and it makes us more human, builds connection and allows us to build team with real integrity.

 

Personally, I am continually influenced and changed by that man, Jesus. In the Gospel of John, we are told that any time anyone questioned his identity, his legitimacy or his authority, his answer was simple: I am, who I am. For us to be authentic, we need to know who we are, so that whoever we are with, we remain true to our core values. Throughout our life’s journey we are continually challenged to decide which way we will walk. Will we walk the easy way of life, in which we allow our ‘ego’ to remain in tact and have people see a projection of ourselves? Or will we choose the more difficult but life-giving way, of letting our ego be stripped back, so that our true self can be seen?

 

What I have witnessed over the last few years, is that leadership can rob people of their humanity. The structures we work within can end up dehumanising us, as the ego becomes puffed up and we find ourselves protecting the image we have projected. As we climb the ladder of responsibility, we can begin to modify our behaviours and as we do so, we begin to subtly let go of our core values. Perhaps we forget where we came from, or we feel the need to protect our position. Perhaps, we’ve never dealt with our own sense of entitlement or the privilege of our background which helped to propel us into positions of influence in the first place. Perhaps we never really confronted our own shadow and have carried on building our own ego project, which somehow permissions us to act in very unhealed ways.  Perhaps we get proud and lose the humility to accept that we don’t know the answer to many of the questions thrown at us, but instead of opening up the conversation towards a collaborative process, we lock down the control and increase the demands on our teams. Whatever the reason, hierarchy so easily dehumanises us, unless we work really hard to subvert it.

 

There is a real art to leading in the midst of complexity, due to the interplay of mechanistic structures and the living systems of which we are a part. The ability to resist the the demanding expectations of the behavioural norms of the machine, whilst ensuring the job gets done and setting a culture of kindness, openness, trust, honour, joy and dare I say it, love, takes bravery, time and audacity. All too often, especially at a regional and national level, I am seeing that people seem to forget who they are and begin to behave in ways that lack authenticity, treating those who were their peers, only a few months previously with disdain. I tire of seeing people talk down their noses at others, or gather people into a room to shout at them, as if this is an effective means of communication. When we see it, we must call it out. We must subvert it before submitting to it. Only by doing so, will we expose it for the phony, imperial nonsense that it is and find a way through to a kinder, more human way of leading. As my great friend, Roger Mitchell says, “Love is the purpose of everything.” A great question for leaders is, “How much love am I loosing here?” If the answer is, “not a lot!”, then maybe think about why on earth you are leading and how you might do it a whole lot more authentically!

 

 

 

 

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Healthy Schools

Last week, I had the privilege of being at Morecambe Bay Community Primary School. The school is a beacon of hope in this area. I found it extremely moving to walk round, with Siobhan Collingwood, the visionary and big-hearted headteacher and see the incredible love displayed by all staff towards the amazing children there. It made me realise again how centrally driven targets often make no sense for so many of our children and communities, especially when the base from which they start is so very different. Siobhan and her team are doing the most incredible job at caring holistically for the children here, dealing with complex behavioural issues with such kindness and brilliance that it brings tears to my eyes, even writing about it. Not only so, but the standard of teaching to then try and help these kids come up to the ‘required standards’, being creative with the resources available, is nothing short of miraculous. I would defy any school inspector to rate this school as anything else than ‘outstanding’.

 
Siobhan and I had a great discussion about the need for health, social care, the voluntary and faith sector, the police and education to work more closely together for the wellbeing of children and young people in our communities. This is already happening in part, through our health and wellbeing partnership and ‘better care together’, but there is far more we can do. We thought about what it might be like if we parachuted fresh into the community now and had to start from scratch, what we might do together…….

 

We would start with stories – we already have many, from the conversations we’ve had in the community, but we want to really listen and be changed by the responses that we hear. We’re so grateful for the work of the ‘poverty truth commission’, helping us to do just that. We would also definitely pool our resources and prioritise key services that would not be taken away once the community begins to thrive, such as parenting classes, cooking lessons, early support services, a radically caring housing sector, preventative policing strategies (now emerging powerfully in partnership with our town and city councils), social care, mental health champions (something Siobhan has already been part of recruiting 150 locally!), children’s centres and adult education centres as a starter for 10. We would overlay this with the things that are working now – there is so much goodness happening and we don’t negate this. We want to ensure that we could see the health inequality gaps close.

 

In order to build on this idea of ‘healthy schools’, we would see kids being active every day – despite, limited grounds space, this school, like many others locally are running a mile a day. There is a great scheme here in which all the kids are learning to cook healthy, nutritious food, building vital life skills needed now and in the future. The breakfast and after school clubs are providing many healthy meals each day for the kids and throughout the summer holidays the schools cook – another woman with an incredibly big heart, opens the hall to feed families, who cannot afford to eat during the long breaks. A huge amount of work is being done around gender equality (have you seen the amazing documentary series “No more boys and girls: can our kids go gender free?” On BBCiplayer?). Kids are also given a huge dose of self esteem and know that they are loved and belong. If only the same level of caring support could be afforded through the transition to high school…..

 

Over the coming months, we hope to co-host some conversations with the community, not on our terms but shaped together with them. Siobhan spent years trying to think of great ideas to get the parents to come into school and interact with her. It wasn’t until the parents set up their own coffee morning in the old garage of the school playground, that she went to meet with them on their terms and started to build some staggeringly life-changing relationships. We know we are changed every time these kind of conversations happen and it blows our world view up so that we can collaborate effectively and co-design services with them. We want to share data with them about health and educational outcomes in order to create a passion for change and do some appreciative enquiry about all the great stuff already embedded in the community. Through these conversations, we want to connect people together and see a social movement for positive change.

The future of Morecambe is bright and full of hope. The communities are strong, the place is beautiful and the people are amazing. Siobhan is just one of many incredible headteachers in this area, committed to one another and this geography through bonds of friendship. If a genuine partnership between health and education can develop here (and it’s part of my vision and ambition to see this done) then who knows what might be possible over the coming months and years?

 

It is time for Morecambe to find its joy again. It has been the joke for too long, but soon it will become the place where the joke is found and everyone will want to know what we’re laughing about.

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Building Healthy Towns and Regions

The other week, I was phoned by a BBC producer to ask if I would take part in a discussion on the Victoria Derbyshire show about how we can build healthy towns. It’s partly due to the work we’re doing here in Morecambe Bay with our communities around being more healthy and well, especially working with schools. Unfortunately, I was away on holiday and missed the call and so didn’t get on the show! But it did get me old grey cells thinking about this whole idea. Here at Lancaster University, we have the Health Innovation Campus, which is helping to design a new ‘healthy town’ in Lancashire. The “Imagination Team” are also hosting a conference this week called “Does Design Care?” But what do we mean by a healthy town and what ingredients might we need to see in our cities in order to say that they are, or are becoming “healthy”?

 

We must get beyond thinking that a healthy town is simply one where there is clean air to breathe and everyone is out jogging, smiling at each other and eating quinoa salads for lunch – it’s all a bit middle class! I would like to make some fairly radical suggestions of what it might mean for a town to be truly healthy, especially having been so inspired by the amazing ‘Doughnut Economics’ by Kate Raworth. I think if we don’t have a vision for what we want our future towns, cities and regions to be like in 50 years, we will not build them! I am often told that you cannot eat an elephant in one go, and we must focus on the small things we can do – eating it one bit at a time – true enough, but we need to hold both things in tension. We need a vision big enough to inspire us to change and then we need to pick up the knives and forks and begin the process of eating it!

 

So, what might healthy towns of the future be like?

In healthy towns:

There are no homeless, not because of social cleansing, but because everyone has a home in which to live.

Design cares enough to ensure that spaces are built which encourage communities to spend time with each other, connecting and collaborating, breaking down isolation and loneliness and facilitating new political space.

There is a creative commons, with plenty of space that belongs to all.

The economy of the town/region is designed to ensure that resources (including land) are redistributed, breaking cycles of poverty and enabling all to flourish. This increases the happiness and health of all and allows a society in which the wellbeing of all matters to all.

The economy of the town/region is designed to ensure regeneration, thus taking care of the environment for future generations. Towns like this will not only be carbon neutral, they will in fact, as Kate Raworth says, become generous in their approach to humanity, other towns and the planet itself.

Children will be nurtured, as part of communities, not as fodder for the economic machine, educated as socially adaptable human beings, understanding their place within the ecosystem of which they are a part.

There will be a culture of positive peace, made possible through non-violence, in which architecture is used to enable communities to live well in the midst of and celebrate difference. Facilitation and mediation will be normative practices when relationships become strained or difficult and the lust for competition and war will be quelled.

There will be a culture of love, in which all are welcome and accepted for who they are. This does not encourage selfishness, nor does it mean that there is no challenge. In fact, love, at its best, is self-giving and others-empowering (Thomas Jay Oord).

There will be a culture of kindness, displayed through humility and respect.

There will be a culture of joy in which people know that they belong and are trusted.

Justice will be restorative, rather than retributive, something which does not negate the need for discipline, but hopes for a better future through grace.

Refugees are welcomed, cared for and also allowed to flourish.

Equality and diversity is celebrated as a norm.

Farming practices are kind to the land.

Business is changing it’s goal, becoming agnostic about growth, but obsessed with how it plays it’s part in improving the wellbeing of all through regeneration, redistribution, repair, reuse, refurbishment, recycling and restoration.

People are valued in their work place and the workplace is a healthy place to be in.

Physical activity and healthy eating are a normal part of every day life. (Thought I’d better add that one in!).

Wherever possible, people die well, surrounded by community who love them.

 

Wouldn’t you love to live in a happy, healthy, wholesome town?! It’s not beyond our grasp. We simply need to adapt the ones we have and build the ones we want! Building together a future that is good for all. Which bit shall we eat first?!

 

 

 

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What Next for General Practice?

Last week, I had a sixth form student spend the week with me. She is hoping to go to medical school and is gaining the necessary work experience ahead of her applications. It was so great to be able to share with her the variance of my work and the great privilege it is to be a GP in the community. On the first day, we saw people with all kinds of problems, often interlinked or overlapping. She was amazed by how well I know my patients, not just the conditions they have, but them as people and the complexities of their lives. At Ash Trees Surgery, the practice where I am a partner, we run personal lists, in which we as GPs always see the same set of patients, supported by 2 other doctors, for times when one of us is not around. It gives us the opportunity of building fantastic therapeutic relationships with the people we serve and we get to know them really well. Our patients love it, we love it, and it has been a ‘traditional model’ of General Practice in our local community.

 

However, things are changing (not immediately in our case, but faster than perhaps we would like), and we (as GPs) and people generally, are going to have to get used to it, not just in Carnforth, but across the whole of the UK. I’m not writing this blog post as an idealist, but as a pragmatist. There are many things I wish were not changing, but we are reaching a point at which the scales are tipping and things simply cannot remain as they have been. Many GPs know this already and are making bold and difficult decisions to try and work differently, but many of us keep harking back to yesteryear and wishing we could turn the clocks back.

 

The issues facing us are stark:

 

1) We simply will not have enough GPs within the next 5 years to carry on working in the ways we have done. 40% of current GPs will be retiring within the next 5 years or moving into other work. (http://www.telegraph.co.uk/science/2017/07/30/nearly-40-per-cent-gps-plan-leave-nhs-within-five-years/).

 

2) The promise of 5000 more GPs will simply not come to fruition and certainly not in the time frame needed. Actually, a plan is afoot to replace some of the GPs with ‘Physician Associates’, people who have a science or allied degree, who have then done a conversation course and can do some (but certainly not all) of the work of a GP. They will also neeed supervision by GPs. Health Education England are having to cut GP training in order to make way for this new breed of health care workers (yet unproven). The Royal College welcomes the development as a support, but not a replacement of GPs. (http://www.pulsetoday.co.uk/your-practice/practice-topics/education/gp-training-cuts-necessary-to-allow-hee-to-develop-physician-associates/20034643.article#.WUrZgli-YHU.twitter)

 

3) The new generation of GPs, do not want to become partners and therefore the old partnership model will soon become entirely unsustainable. The results of a recent survey, carried out by Pulse of GP Trainers about the future careers aspirations of their trainees is pretty stark:

Only 6% said their trainees wanted to go into partnerships;
49% said their trainees wanted to become locums;
28% said their trainees wanted to go abroad
30% said their trainees wanted to find a salaried post;
4% said their trainees wanted to change career.

 

So, in summary, the older GPs are retiring, we’re not recruiting enough new GPs and those we are recruiting, simply don’t want to work in the ways we have been used to.

 

The Five Year Forward View has been trying to encourage us all to reimagine General Practice and how we might hold true to the values of this bedrock of the NHS, whilst adapting towards the future that is coming. I think we have some options, and GPs need to think clearly and carefully about which direction they want to head in. But even more importantly, the people of the UK need to recognise that change is afoot and GPs are simply unable to work as we have done previously. The demand is too great and the resource simply is not there to carry on as we were.

 

The first option, is for GPs to bury their heads in the sand and hope that all this might not be true, to become more entrenched in their position and wait for things to be done to them. I believe this will be harmful for General Practice itself, as it will mean a decrease in resources, an increasingly burdensome workload and significant burnout. But I also believe it is detrimental to the NHS as a whole. We neeed to break down the barriers that have divided us and work more holistically across what is a very complex system. Waving the flag of traditional General Practice is admirable in some ways, but I think it might prevent us from stepping into the future that the nation now needs from its NHS.

 

The second option is for GPs to federate with other practices, keeping hold of some of what they love, (a perceived sense of autonomy, the ability to run their own business, to stay part of a smaller team) whilst benefiting from sharing some functions like training, recruitment and maybe some staff with other practices. We have done this in Morecambe Bay (thanks to the Stirling work of Rahul Keith, John Miles, Lauren Butler, Richard Russell, Graham Atkinson, Chris Coldwell et al).  However, the federated model has to be given true commitment and financial support or it will accomplish very little. Practices cannot go back to competitive mindsets or taking care of their own needs first. It requires a bigger heart and a more open mind with genuine behavioural change.

 

The third option is to form super-practices. We have two in our area now (Bay Medical Group in Morecambe – > 60000 patients  and Lancaster Medical Practice >50000 – also both part of our federation). There are some huge advantages in working “at scale”, but it is not easy and certainly not a smooth transition. GPs have to learn to trust each other and be willing to have difficult conversations around buildings, drawings, policies etc, let alone learning to work differently. But more than that it is very hard to learn how to deliver really good General Practice in a personal way, whilst trying to reconfigure the team and establishing a really good culture. However, this model definitely allows new ways of working to be more easily acheivable, if given appropriate OD support. Some recent work done in Gosport and showcased by the King’s Fund showed that perhaps only 9% of people who phone asking to see a GP actually need to see a GP. The reality is that people have become used to seeing their GP, but often they could be seen and treated more effectively by a pharmacist, a nurse, a nurse practitioner, a physiotherapist, a mental health worker, a physician associate or a health coach. Perhaps GPs need to let go, whilst patients learn to trust the expertise of others? How do we transition to this kind of approach without losing that amazing knowledge of a community and complex social dynamics, often held by a GP? How does a Multi-Disciplinary team function effectively for the best care possible for patients in such a dynamic? We are in danger of losing something very precious, but can we somehow hold onto it in a different way?

 

The fourth option is to allow a “take-over” and become a more active player in an Accountable Care Organisation. The take-over approach is not straightforward, but I’m not sure it is as terrible as it appears to many GP colleagues. What if an acute trust set up a separate company, lead by a GP as medical director, who understood and held the true values of General Practice in his/her heart (as they have done in Yeovil – https://www.england.nhs.uk/blog/paul-mears-berge-balian/)? The company, run by General Practitioners, holding true to the core delivery of General Practice, without all the difficulties of running a business, HR issues, estates, etc etc but with all the benefits of shared IT systems, easier access to scans, no duplication of work and direct access to services without all the current clunkiness, not to mention protected admin time! What if the salary was right and the dross was removed? What is it exactly that would not be appealing about this? It is interesting to me. Only a couple of years ago I would have been utterly opposed to this idea, but having given it thought and time over several months, exploring the possibilities involved, I’m in the place of thinking that the benefits probably outweigh the negatives both for GPs and our patients.

 

What we need right now is for us all to accept that the NHS, as we have known it is no longer functioning in a way that meets the need of the population we seek to serve. We know we need a greater emphasis on prevention and population health (I have blogged on this many times before and will do so again!). We also know that the system itself is vastly complex and is in need of major reform and reconfiguration. We need this not only for the people who use the NHS, but for those of us who work in it and are in danger of serious burn out. I hope with all my heart that General Practice does not drag its feet and prevent the revolution that is needed. Our case for more resource and more recognition of the fabulous work we do will only gain favour, if we also show that we are willing to be a part of the whole and a part of the change that must ensue.

 

 

 

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Social Movements and the Future of Healthcare


As the crisis in the Western World deepens, and the growing reality sets in that business as usual simply can no longer continue nor solve our problems, our systems must change the way they view, deal with and hold onto power. The NHS is no exception. If we want a health and social care system that is of the highest quality, safe, sustainable and economically viable for the future, we need to understand the power of social movements, both within our systems and through the wider society. This is something we are really committed to in Morecambe Bay and so it was with great delight that I listened to the excellent Helen Bevan, talk about just how vital social movements are for the NHS and healthcare, worldwide at the recent IHI conference in London, Quality 2017. This blog will be an amalgamation of what Helen shared and my own thoughts about our early experiences with social movements.

 

 

A social movement in health and social care involves us all learning to connect, collaborate, cooperate, cocreate and coproduce at a level we have never done so, until now. But our circumstances are forcing us to reconsider the ways in which we work. We need the creative substance that is within our teams to be heard and harnessed so that we cut our waste and work more effectively together. The issues we face, need facing by us all, together; not by some board in an isolated room, making decisions based on diktats from on high, on behalf of us all.  But even this will not be enough. Those of us stuck in the system have become too homogenized in our thinking for us to do this exclusively from within. We need our citizens to help us re-imagine what it means for us to be healthy and well. We must stop designing things for our communities or doing things to them, instead we must design and do things with them. We must analyse, create and enact together and to do this, we must learn to solve the issues of power.

 

Helen Bevan, with her background in social science, demonstrates the great debate about the interplay between our organisational structures (rules) and agency (freedom) when it comes to effecting change. Where does the “permission” come from to enact the change we need to see? Is it externally generated by those in positions of power, or is it internally generated by a personal motivation? Our experience in Carnforth and Morecambe in community conversations has been a bit of both. There are many people of incredible heart and goodness, waiting to do something new and good that will positively affect the health and wellbeing of society, but are perhaps waiting for that sense of community backing, support, encouragement or indeed permission. With a bit of coaching or spurring on, we have seen some amazing initiatives begin that are bringing transformational work into our area and causing us all think differently. We need both individual agency AND corporate agency. Helen describes individual agency as being when people get more power and control in their lives – we see this in patient activation, shared-decision making and self-care – a greater sense of autonomy and responsibility. Collective agency, on the other hand, is where we see people act together, united by a common cause, harnessing the power and influence of the group whilst building mutual trust.

 

 

We have seen this used powerfully, in just one example by our maternity liaison service committee, who together have challenged our system to think more carefully about how we communicate to women, especially at key or stressful moments of their obstetric care. These stories are now a compulsory part of training for all who work in our maternity service and have significantly improved both our skill mix and ability to provide excellent care.
What is absolutely vital to understand is that we do not become transformed alone. We are transformed when we are in relationship with others (Hahrie Han). The problem is that we don’t really encounter the “other” enough to be changed. However,  when we let go of the kind of power that is held by the few, pushes others down, uses command and control, that is closed and transactional, and instead embrace a power that is held by the many, shared, open and relational, then we can begin to see the change we need (Hirschman and Ganz).

David Holzmer says that we are witnessing the collapse of expertise and the rise of collaborative sense-making. I would suggest that this has been going on for some time, but our systems have been incredibly slow at catching onto the change around us.

 

Now, what is hugely encouraging is this: research by Kollectif shows that you only need 3% of people in an organisation/society to drive the conversations with 90% of other people. In other words, you don’t have to get everyone on board from the word go. You find your passionate people with a sense of agency, infect them with the virus and watch it spread. These people need to be a mixture of ‘lone wolves’, mobilisers and organisers. Lone wolves are people who have been trying to help change happen for a long time but can sometimes feel like an annoyance to the system, so they are given tokenistic positions, patted on the head and patronised into exhaustion. Mobilisers build power by calling large numbers of people to contribute, engage in change and take action. Organisers build power by growing leaders in a distributed network, building a community and protecting its strength. We need all of them, though mobilisers and organisers will be the most effective in creating agency and bringing about lasting change  (Hahrie Han).

Joe Simpson says that ” great social movements get their energy by growing a distributed leadership.” The cult of celebrity can be powerful, but is not effective. The beautiful thing about a social movement is that is depends not on money, materials and technology but on relationships, commitment and community, and as the movement grows, these resources increase, rather than diminish. The problem, as Don Berwick puts it, is that leaders in position of strategic influence, are simply not seeing the resources available to the biggest problems we are facing.

 

Jason Leitch and Derek Feeley have powerfully shown that performance management (keeping the power), based on targets, sanctions and inspections can only get us so far. Quality improvement (sharing the power) gets us a little further, but mobilising social action, or co-production (ceding power) has a far greater potential to bring lasting change and far better outcomes for all.

 

So, how do we catalyze a social movement and how would we know if the movement was being “successful”? Well, our experience in Morecambe Bay is that you start with the 3%. You start with those who are drawn to the conversation, who recognise the need for change and who want to be part of it. You start with transparency, with openness, honesty and vulnerability about the mess we find ourselves in and the truth that we no longer have what it takes to solve the problem. And you start with really good questions and then deeply listen to the conversation which is emerging so that we ourselves are changed and can therefore be part of the emergence of something new, which operates on an entirely different kind of power.

You might call this a re-humanisation of our systems based on love, trust and the hope of a positive peace for all. But this social movement is not aiming for some kind of hippy experience in which we are all sat round camp fires, singing kum-ba-yah! This social movement is looking to cause our communities to flourish with a sense of health and wellbeing, to have a health and social care movement that is safe, sustainable, socially just and truly excellent, serving the needs of the wider community to grow stronger with individuals learning, growing and developing in their capacity to live well. That is what we must measure!
And so we need disruptive co-creation, which breaks through the top-town/bottom-up approach and causes us to see and hear like we have never done before. It is hugely exciting and enables managers to stop feeling like they have to extract as much performance as possible from the system, flogging the workforce, blocking change and innovation and inadvertently driving down the quality of care in the process.

The invitation is instead to become part of the change that we all long for. If we’re going to have an NHS in the future, we have to give it back to the people and work with them. In order to do this, we have to deal with and change our relationship with the very notion of power – something I will turn my attention to on the next blog!

 

 

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