Tag: kate raworth

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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How Do We Build a City That Works For Everyone?

I recently hosted a couple of conversations for people in the city of Lancaster, UK, in which we explored this question together: “How Do We Build a City that Works for Everyone?” We framed the conversation (which we had using a ‘World Café’)from two current and important concepts. Firstly, the great work of Kate Raworth in ‘Doughnut Economics’ – how do we create a city that is socially just for the people who live here and that is environmentally sustainable for the future? In other words, how do we ensure we have an economy that is distributive and regenerative by design? Secondly, we drew on the important work of Sandro Galea (Professor of Epidemiology at Boston State) and his concept of the Goldfish bowl as a way of thinking about ‘Population Health’ or Epidemiology (see my last blog). Politics IS health, according to Galea.

 

One of my favourite quotes is from Einstein, when he said that “If I had 60 minutes to save the world, I would spend 55 minutes trying to find the right question and then I could solve the problem in 5 minutes.” It turns out that the question we used itself is problematic at a few levels! Here are some of the questions we found ourselves wrestling with: Do we need to build the city, when it is already here?! What do we really mean by ‘the city’ – is it people and communities or more than that? What do we mean by ‘works for’? That felt to some like we were settling for something that was just enough, maybe scraping by, rather than thriving! And who do we mean by everyone?! This didn’t stop us having a a great discussion, but highlights how powerful the perspectives and biases we bring into the room can be!

 

Despite not having a perfect question, (and hopefully, by the time we host 3 much bigger conversations across the city during 2019, we may have honed something more helpful!), some key themes emerged, through our generative conversation. 

 

  1. Relationships are vital! We want to live in a city which really does “work” for everyone. So, we want to give value to the currently unheard voices and we want to value diversity and inclusivity. Taking time to get to know neighbours and colleagues grows a richness of community. We want to live in a city that values love and kindness in how we treat ourselves and other people.
  2. We need to build on the amazing assets and skills that we already have in the city. If we made space and time to discover and share these skills with each other more, we would develop a richer life experience within our communities. This is an expression of ‘gift economy’ and ‘reciprocity’, which Charles Eisenstein writes powerfully about in his book ‘Sacred Economics’). It builds on voluntary power, and may require a reimagining of how we work and what we value in how we invest our time, energy and resources. We also have so many incredible physical assets in this area, which we don’t tap into enough or perhaps make fully accessible for all who live in the city.
  3. People want to be part of the change, not have change happen to them! This requires much better engagement and democratic discussion about how budgets are spent, for example or how land is developed. Somehow, there needs to be a better safeguarding against ‘invested interests’ and ‘dodgy deals’ with far more transparency about how decisions are made. Such a process, it is believed, would enable far better personal and corporate responsibility when it comes to caring for the fabric of the city and the people who live here, similar to what has been developed in Wigan. There was a recognition that when we talk about personal choice and responsibility that this is much more possible for some people and communities than others. However, it was felt that increasing self-esteem and a sense of belonging would enable more personal responsibility and choice.
  4. Housing really matters. The physical environment is actually causing fragmentation and silos. There were many more questions than answers here – but that’s ok – this is an iterative process, and we don’t have to solve everything in one go. So…how do we create really good social housing? How could we redesign the spaces of the city to encourage togetherness and community? How do protect green spaces in the process and take care of the city’s drainage (strong memories of the recent floods)? How could we ensure that everyone has a home to live in, and what might that mean for both the homeless and also for single people?
  5. We want an education system that really values the unique beauty of each child, treats each one with compassion, mindful of what traumas they may be experiencing and values creativity and activity in education just as much as academic outcomes. We care about who our children become, not just about what exams they pass. So we recognise that we have a measurement problem but we’re not quite sure yet what to do about it! 
  6. We need to invest in our children and young people by providing physical spaces in which our young people can feel safe and not bored! Many have been affected by the closure of children’s and youth centres. If we are to really invest in our children and young people, there was a sense that we also need to provide parenting classes across the board to pregnant couples and through ‘family centres’ and schools across the district.
  7. We want to create a greater sense of value for our older citizens. There were many people present who felt they have things to offer, but don’t have an obvious outlet. Involving those retired from paid work more in the life of the city would break isolation and feed the gift economy. 
  8. Business needs to thrive in a way that really values entrepreneurial gift and allows it to flourish, whilst holding it true to the ideas and principles of the doughnut and the goldfish! How could the business community serve the needs of the city and how can the city enable business to really thrive, creating jobs, whilst caring for the environment and the needs of the people who live here? Kate Raworth’s work could really help us!
  9. Transport systems need to be redesigned to encourage more cycling and walking or the use of green public transport alternatives. Transport routes also need to join up our communities more effectively to improve opportunities for those who live in areas that are currently more financially deprived. 
  10. If we are to really improve health and wellbeing and care for the environment, then we need to see this written into EVERY policy decision. If politics IS health, as per Sandro Galea, then we need to take this seriously and stop making policies which do not care for these things.
  11. We want to be part of city that does welfare well! We think there are many possible new ways of doing things more effectively, as described in Hilary Cottam’s book, ‘Radical Help – Reimagining the Welfare State’. One of the things felt to be important is increasing skills in money management (85% of people living in social housing in this district are in debt to the city council -though this is certainly not only due to poor money management , but an unjust system that isn’t working for the majority). Morecambe Bay Credit Union offers an alternative economy as a way of using micro finance in our local geography.
  12. We need better ways to communicate and connect people together. There is smart, digital technology that could help us here….perhaps a Lancaster portal, that connects us together more effectively and helps facilitate the sharing of our assets and gifts.

 

Wowsers! Not bad for 2 conversations of 90 minutes each! Just imagine what a phenomenal city Lancaster might become over the next 10-20 years, if we set out on a journey together to build this kind of city! What is stopping us, I wonder?! #enoughnow #togetherwecan

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Heathrow and Health

If MPs are serious about the health of the population (and it seems they are, given recent promises of increased funding for the NHS), then when they vote later today about whether or not Heathrow airport should get a third runway and therefore a programme of expansion, they should ask them selves the following questions:

 

  1. Are we taking seriously the Public Health England, World Health Organisation and World Health Innovation Summit advice seriously to write health into ALL policies? If so, will the expansion of Heathrow improve or worsen health outcomes, given that air pollution is the second biggest attributal cause to early death in England? How much consideration is given to health outcomes currently when it comes to transport, energy or business policies?
  2. Will the expansion of Heathrow prevent exposures to hazards that cause disease or injury? We know that pollution is worse in our more deprived, urban populations. We know that people in these areas are more likely to suffer with respiratory conditions, such as asthma and COPD. Therefore we must ask, is the expansion of Heathrow likely to improve respiratory conditions in London or worsen them?
  3. Will the expansion of Heathrow help to tackle the underlying social determinants of health? No, as Kate Raworth (Doughnut Economics) and Greg Fell (DPH for Sheffield) have demonstrated, sadly it won’t. It may help certain businesses to thrive, and may help stave off some of the economic downturn post Brexit, but the premise is still built on the idea that trickle down economics works and helps to tackle inequality (and therefore health inequality), which it does not.

 

It seems very odd to be making a promise to invest more money in the NHS, whilst acting through other policies to actually make health worse. Some very clear thought is needed ahead of this vote.

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Who is Responsible for Your Health?

Who should take responsibility for you health? Sounds like a straightforward question, doesn’t it? But I get so frustrated when complex issues get squashed into simplified, silo-thinking, ready for twitter or media sound bites, or the under-girding of political ideologies.

So….just as the economy is not just made up of the interplay between business and the household, but is in fact far more rich and complex, so too the interplay of responsibility for our own health.

Kate Raworth, really helpfully uses the following diagram to help us rethink the components of the economy. I would like to suggest that we use it to think about health, also.

So…who is responsible for your health and wellbeing?

  1. Your Family/Household
  2. Society/The Commons
  3. The Market
  4. The State
  5. You

In some ways, I feel like all of these are obvious, in their own way, but I will just unpack each one a little bit more.

 

Your Family/Household

We all have needs. We need to know we are provided for (water, food, clothes etc), safe, loved, welcome, encouraged, disciplined and given place to dream and live those dream out. It is the role of our families or the household to which we belong to ensure those things happen as we grow. So much of our ill-health, our brokenness and our long term physical and psychological pain is because these basic needs were never met and left us without a sense of wholeness. The lack of met need, has a huge impact on the development of our personality and character. When we speak of ‘personality disorders’, each type has it’s roots in early life when needs were unmet and therefore parts of the personality remained undeveloped. Let’s face it – no family is perfect! And so, I would argue, that all of us have ‘disordered personalities’, and until we confront the shadow parts of ourselves that are trying to overcome this sense of loss or inadequacy, we continue to project an ego version of ourselves to those around us. We do so to cover over this pain, but facing it head on and allowing ourselves to fess up to our deepest needs, would actually lead to us being a great deal more healthy.

When I work with head teachers and ask them what the biggest need they have in their school, the answer is almost always ‘parenting classes’. However, there are very few providers of this available (due to cuts at a county council level) and the classes available are often very ‘middle class’ in their approach. We need to completely rethink parenting classes in the context of the poverty-truth commission and think about less twee ways to really engage with communities about how we raise happy and healthy kids. The truth that Adverse Childhood Experiences are our greatest public health crisis is not going away. Grasping this nettle is going to be painful but really necessary if we are to breathe health and wellbeing into our society.

 

Society/The Commons

Just as we get our needs met by those in our immediate household, the same is true of society. The way we treat children, the things we expose them to, the way we love them and educate them has a massive impact on their current future health and wellbeing. It’s becoming clear that social media is causing significant harm to our mental health as a nation, particularly our young people, and yet we don’t know how to curb our enthusiasm for all our technology…let alone the rise of the robots…

The commons is fast disappearing, too easily privatized and made available to those who can afford it. How do we safeguard the commons and use it for the benefit of all? What would the Diggers say to us now? The breakdown of our communities, with increasing isolation and loneliness is having a detrimental effect on our wellbeing. What can we do to recover the spaces that belong to us all and help us rediscover the joy of connecting and being together?

The commons is also about our corporate voice. It is only really vast people movements, speaking with one voice that can really cause governments to sit up, listen and take heed of the needs of the people. It is only together, that we will make enough noise to change the health and wellbeing of all of us for the better. How might we speak and act together in a way that will take corporate responsibility for all our health and wellbeing?

 

The Market

Oh the benevolent hand of the market! If only…. But the Market plays an absolutely key (though currently over played) part in our economy and our health and wellbeing. We know for a fact that advertising is deliberately trying to misinform us so that we make irrational decisions. A key component is to make people feel worse about themselves so that they buy things they simply do not need. Supermarkets are being challenged for the ways they deliberately place products and arrange their stores to cause people to buy more unhealthy things and food chains are constantly trying to ‘up-sell’ their unhealthy products and downgrade our health in the process. They evangelize the masses with the idea that we are all free to make our own choices, but if this were so, they would not spend the billions of pounds involved in socially engineering our choices, so that we ‘freely’ choose that which harms us! Oh for a market that might redefine it’s moral code! The market could do SO much good, but unharnessed and left without true accountability or consequences, it serves to damage our health – something it is truly responsible for.

 

The State

The state has a vital role and responsibility in caring for all of our health and when it washes it’s hands of that responsibility or tries to pass it over, we see a massive rise in health inequalities and overall worse-health for all. The NHS in the UK is one of the great triumphs of the state. Providing brilliant healthcare for those who need it whenever they are unwell is truly amazing. Imagine not being able to afford this because it depended on keeping up with insurance bills. It is not uncommon for us to see people in General Practice, who literally cannot afford to feed their families any more and are having to make some incredibly difficult choices (made far worse by long school holidays). Easy to point the finger and start creating a narrative about how it’s “all their fault”, but far harder to hear the truth of what it is really like to be a lived-expert in poverty and the trap it creates and harder still to look to alternative solutions, rather than believe the austerity narrative. There is clear evidence that the more unequal a society becomes, the worse the health outcomes – both physical and mental. When the market is allowed to behave exactly as it wants, we also see the health of people suffer. It is only through the right kind of government that the market can be tamed. It is only with the right kind of legislation that the economy can be skewed towards redistribution and regeneration of the resources needed – this would need to include a radically feminist approach that works on behalf of women, in particular, for equal opportunity, pay and recognition of just how much the ‘household economy’ contributes to the overall wellbeing of the nation. It is only the right kind of leadership that will tackle the inequalities we see and refuse to be wined and dined into maintaining the status quo. It is only brave leadership that will take the ecological issues, like plastic in the oceans, massive over antibiotic use in animals, and ongoing air and river pollution that will give us a healthy planet and human population in the future.

 

You

And where possible, and for some given various health issues, this is more possible for some than others – we do not all have an equal starting place or a level playing field – where we can  – we do have a responsibility to ourselves and to the wider society to care for our own health and wellbeing, so that when the health and social services are needed, they are available for all. It also means using the health and social care services in a way that creates sustainability, being grateful for them and ensuring they and the people who work in them are not abused.

 

It’s complex, but it’s vital that too much emphasis is not put on any one area. We must not play the blame game, especially not towards individuals when we haven’t taken the time to hear their story, nor understood the wider context of the role of the other vital players on the field. Each aspect of the economy plays a massive role in the health and wellbeing of the nation, and it is high time that each plays it’s relevant part to its fullest ability.

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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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The Ethics of Health Economics

The ethics of Healthcare is about 2000 years ahead of the ethics of Health Economics! All doctors in the UK take an amended Hippocratic oath when we qualify, in which we promise to:

 

  • Do no harm
  • Prioritise the patient
  • Treat the whole person, not just the symptom
  • Obtain prior informed consent
  • Call on the expertise of others when needed

 

We also have our ethical code:

 

  • Benficence – i.e. seek to do good
  • Non-maleficence – i.e. don’t deliberately do harm
  • Justice i.e. treat everyone equally
  • Autonomy – i.e. respect the wishes of your patient

 

Kate Raworth argues in her simply marvellous book, Doughnut economics (in the Chapter “Get Savvy With Systems”), that the discipline of Economics simply does not have any such moral or ethical code. In fact, as George Di Martino puts it, “it is entirely cavalier regarding its responsibilities”. But in a world, based on theories (most of which are entirely outdated and impotent in solving the global issues we face today), it is vital that an ethical code is written on which economic decisions can be based. She makes the following suggestions:

 

  • Act in service to human prosperity in a flourishing web of life, recognising all that it depends upon.
  • Respect autonomy in the communities that you serve, ensuring their engagement and consent.
  • Be prudential in policy making, seeking to minimise the risk of harm -especially to the most vulnerable – in the face of uncertainty.
  • Work with humility, by making transparent the assumptions and shortcomings of your models and by recognising alternative economic perspectives and tools.

 

In some ways, I think you could take the ethical code of the medical world and simply apply it that of economics, but the four principles above give us a good starting framework.

 

The reason I want to explore this whole idea and will give some further blogs to this area of health economics is that, to my mind, it is ludicrous to be talking about ‘reimagining health’, if we are not also in the same breath ‘reimagining health economics’ or indeed ‘reimagining economics’. Much of what is happening within the world of health and social care at the moment is being driven by an economic model that lacks a moral compass or an ethical frame work. It is high time that this changed! Decisions made about how a health and social care system is organised and governed hugely impacts on how that health and social care is subsequently delivered. We cannot afford to separate our ethical principles from our commissioning strategies. There must be far more synergy between the two.

 

I love this quote from Donella Meadows:

 

“The future can’t be predicted, but it can be envisioned and brought lovingly into being. Systems can’t be controlled, but they can be designed and redesigned (emphasis mine). We can listen to what the whole system tells us, and discover how its properties and our values can work together to bring forth something much better than can ever be produced by our will alone”.

 

Plenty to think about there!

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